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COMMONWEALTII OI, MASS�ICIIUSETTS ✓%`
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Board of Health, i"'1 i4"r.-.�
APPLICATION FOR PERMIT
Application for a Permit to Construct(y} Repair( ) Upgracle(y% Abandon( ) - fjXComplete System ❑ Individual Components
Location S LL - '
Owners Name —
Map/Parcel#
Address
Lot#
Telephone# g.-39k� - O
Installer's Name
Designer's Name t
AddressAddress
Telephone# --d
Telephone#
Type of Building C t/f tisk Lot Size!:? sq. ft.
Dwelling - No. of Bedrooms Fn{[4 Garbage grinder kt�o
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) //D gpd Calculated design flow y!5!n Design flow provided !/4/!!! .gpd
Plan: Date /O O �2Number ol'sheets Revision Date
Title r?,P¢-/uZo
Description of Soil (s) n - q' j=iL� % = l !f " L o./.u�l .,...1.�7 /� _ - .,2�° ' /i /e4�_49,dld
Soil Evaluator Form No. Name of Soil Lvaluatm:.,_P*(:1t�.d,4r Date of Evaluation d •- I r
DESCRIPTION OFREPAIRS ORAITERATIONS W 1-l^1 7,'-_t,sj4li4r)t, .�.�ss"or o c-, I¢L�" nv
�' �f r /ems! 61/' Ird.✓-r- a-• ! (.t_' J`�L^t, !' 7I ! n x
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the s`y`stem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _tea Raja Date //- i-^ o
No. "' "� '�' V 9 ��' FEE m d {W9
COMMONWEALIII OF MASSACHUSETTS
BomdOfHranh, 1%$AI ale i A MA.
CEI1TIFICATE'OF COMPLIANCE -
Description of Work: ❑ Individual Component(s) U&mplete System
The undersigned hereby certify that the Sewyage Disposal System; Constructed (�J, Repaired ( ), Upgraded,(r"f , Abandoned ( )
by: P"•.C.Iti'«d .1r
at ti_Stk'A jC•t/F-l� °s- /,l'f"f r— 1.0c_f7-�b'�9.�lF,a.1,^A�1
has been installe I in accordance with the p)ovisigns of„3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. b `i ) , dated ,/C /` �� Approved n Desi rFlow 'AW/gpd)
Installer .f- K _. .t'�t --` �f.'r✓ 1: •'=''..
Designer: L',._/g' SU;i.aC" t..dc� Inspector: .F A/ C.. ti..k"%,''"�G Date: l-#I`Arc'%f
The issuance of this permit shall not be construed as a guarrautrleee that the system will function as designed.
No. "u"' t��Lt,..,.. FEE ".---"' t7L.'p
p Yom. 6✓ UA.
COMMONWEALT-1-I OF MASSAC-IJUSETTS la..tr,
Board of Health, S/de",Ii-to.T-6 MA.
DISPOSAL SYSTEyI CONSTUCTION PERMIT
Permission is hereby granted to; Consn'uct(vT Repair( ) Upgrade(✓)_ Abandon ( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. i dated %✓F %�
Provided: Construction shall be completed with ars of the date of this pe�it. All local conditions must be met.
Form 1255 aev.5/95 A.M. SWkln Co. Boston, MA Date v 6 ! Board of Health / iv"_�r! �" '�" �'``^•"°^'s—�" �