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Board of Health, A& Moms , MA.
APPLICATION FOP, DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon() - �mplete System ❑ Individual Components
Location
a
"f " Owner's Name
Map/Parcel#
Address (. .` (
r
Lot#
Telephone#
rl - 5'8t
Installer's NameDesigner's
Namefibac
(Sf d
Address;
E.6enoksAddress
Telephone#
q O a& ./ Telephone# 6
9
4
Type of Building -� Lot Size s ft.
q•
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 .� V
Plan: Date Number of sheets
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS Is O-11
Design flow provided gpd
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal ystem in accordance with the provisions of TITLE 5 and
furtherMHU
1�thoperation until a Certificate of m ` has been issued by the Board of Health.
Signed Date I
t&!.
No. COMMONWEALTH Of MASSACHUSE&S � FEE
Board of Health,I`1 r� 1M , MA.
CERTIFICATE OF COMVANCE
Description of Work: ❑ Individual Component(s) Uzomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: U
at -7-I-f 1 i P4 L- D J ..
has been installed in accordance with the provisions of 140 CMR 15.00 (Title 5) and�thearoved design plans/as-built plans relating to
application No. t dated -/� j Approved Design Flow-/.( d)
Installer /
--/-/
Designer: Pjsc .-, Inspector: � � Date:
s
The issuance of this permit all not be construed as a gua to that the system will function as designed.
No.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, )LALP-1M.0 VT_H , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within �s-ofthe date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date l%� Board of Health ' : `C' rZl
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