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COMMONWEALTH LTH ®f ��] AS'�S�ACHUSETTS Z� �
Board of Health, YAP-M0yrg mi.
'APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to .Construct( ) Repair grade( ) Abandon( ) - ❑ Complete System. -e0 di dual Components
Location
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Owner's Name
Map/Parcel#
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Address S-eAvj
Lot#
Telephone#
Installer's Name
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Designer's Name
Address 3 a
TiA r _
Address
Telephone#SEE
Telephone#
Type .of Building' �J �! Q Lot Size sq. ft.
Dwelling - No. ,of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers (' ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan Date Number of sheets _ Revision Date
Title
Description of Soil(s)'
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS { l° 1.1 '. e. u pex t-14 V ;- C- I-)
The: undersigned.agrees to install the above described Individual Sewage.Disposal System.in accordance with the provisions of TITLE 5 and
further agr s of to lace the system in operation until a Certificate of gbmppmce has been issued by the Board of Health.
Signed Date
Inspections
No. 04 -DC -1 Cj "',?J" 4qo A � 1/ / FEF, 6"6 X00
COMMONWEALTH OF MASSACHUSETTS
Board'o f Health; -&9=W10 V-04 , MA.
��..--`` CERTIFICATE Of COMPLIANCE � % y� '%� �, ' n
Description.of Work. "Ci Individual Component(s) 0 Complete System �J�/ /./l / 6- Jd✓U�
The upyd 'gned hereby cc tify that the Sewage Disposal System; Constructed O:. Repaired, graded ( ) , Abandoned
by J o Cl",X"
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has been installed in accorde with the pr visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. Zf 2 ,., dda��te__d, Approved Design Flow "'""`~' (gpd)
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Installer CpO 1 7 1 l �l� �- J
Designer:--�^�""'" Inspector::
6. Date:
The issuance of thisrpermit ;shall not be construed as a guarantee that the system will function as designed.
No. ice"' ! j'7 l Cot,��)ot -? CAVA `I Q6- FEE
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, T % M0 017+ , AM.
DISPOSAL SYSTEM STEM CONSTRUCTION -PERMIT
Permission is hereby granted to
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Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application. for
Disposal System Construction Permit No _; dated
Provided: Construction shall be completed withinrs of the date of thisperrpi. t. All local conditions must be met.
Porro 1255 Rev. 5196; A.M. Sulkin Co. Charlestown, MA Date li Board of Health ,!^