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COMMONWEALTH OF MASSACHUSETTS
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BoardofHealth,
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a. /let P. LIGATION FOR DISPOSAL SYSTEM CON TRUCTION PERMIT
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Application for a Permit to Construct( ) Repair( ) Upgrade(..-KAO bandon- Complete System ❑ Individual Components:
Locatoa Z,$ Mf-rr Moues+ W2A 0,crn6J*1•%
Owner's Name ckmeS Coco
Map/Parcel# 231 15
Address 2$ MC( -r Moon+ ?,00+d• W, gcmoJ��
Lot# $
Telephone#
Installer's Name iLxcovo.}i�c►
Designer's Name F710,v-,e rC,nVirot�nert}'o,l
Address a) -l4 [,�ovk* l305a�dui.o� Ma
Address (7 p, �t 33l I�ocuj;(��n Mo.
Telephone# Sora. 14'71• 0tpS3
Telephone# 1-1y. qqy• \\bb
Type of Building Lot Size 3, (o dd t�" sq. ft
Dwelling - No. of Bedrooms _ 3 Garbage grinder. ( )
Other - Type of Building No, of persons Showers (' ), Cafeteria.
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design rflow provided gpd
Plan: Date (o 1Z 2019 Number of sheets _ �- Revision Date
Title
Description of Soil(s).
Soil Evaltuator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS MW Tank, b -b" C.nd SAs
The undersign d,agrees to install the above described Individual Sewage.Disposal System in accordance with the provisions. of TITLE 5 and;
further to not ce the system in operation until a Certificate of Com fiance has been issued by the Board of Health.
Signed � _ Date 6 2S
.
No. 60 as DC i9 —358 q �.co
COMMONWEALTH OF MASSACHUSETTS
Board of Health, � f � , MA.
CERTIFICATE Of COMPLIANCE -�' � � s' � � J� a � � 7
Description of Work: ❑ Individual Component(s)omplete System r
The undersiged hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned { )
at
has been installe ac ce with the..P�ro��si sof CMR 15.00 (Title 5) ai t proved design plans/as-built plans relating to.
application No. ! dated l �lApproved Design Flow (gpd)
Installer1 c...�`�
Designer: Inspecto�ntee
Date:Ilk
The issuarIce of. tbis permit shall not be construed as at. the system will function as designed.
No. j/ / V 1� { J C�f� ` FEE J 06
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COMMONWEALTH Of MASSACHUSETTS � �D
Board of Health,�r(Zl Ot i 1�- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;: Construct( ) Repair( ) Upgrade- Abandon( ) an individual sewage disposal system
at . ,:� B M;F�'-J V\40001 i -D as described in the application. for
Disposal System Construction Permit No. /rdated
Provided: Construction shall be completed withiiT rs of the, date of this permit, All local con .'tions must be met.
Form 1255 Rev. 5/96: A.M. Sulkln Co. Charlestown, MA Date � Board of Health -
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No.
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