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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE J COMMONWEALTH \ Of MASSAC14USETTS Board of Health, 7ib=07W , MA. APPLICATION FOP, ISI P®SAL SYSTEM CO2omplete STRUCTIr1ndi MIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - Syste ual Components Location 00 (yj Owner's Name Map/Parcel# I —[ Address Lot# Go Telephone# Installer's Name pf" Designer's Name Address< IIt ki (?i Address Telephone# 5 2C 2 00 7 7 q -71L -n`) Telephone# Type of Building -V Dwelling Dwelling - No. of Bedrooms. Other - Type of Building _ Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil (s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS The uni further Signed Inspections gpd Calculated design flow Number of sheets Name of Soil Evaluator No. of persons 9 - Lot Size sq. ft. _ Garbage grinder ( ) Showers( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and g e sys ration until a Certificate of Com li has been issued by the Board of Health. 7 Date No. FEE COMMON EALT14 OF MASSACHUSETTS V'I' Board of Health, �A �z.li�a , MA. CERTIFICATE OF COMPLIANCE Description of Work: Vndividual Component(s) ❑ Complete System The un ersigned he by certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), A andoned ( ) by: , �G� Q C 0- C ( O L s at < ©0 U has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. �dated 1 �� Approved Design Flow (gpd) n Installer ACCP ti S �� Q l_ �a C) (' �Otl S '� C (1 SP4 t�l' Designer: Inspector: X& AIM Datb: dzlk, ✓ G The issuance of this permit shall not be construed as a guarantee that the system will function as designed. C,0001014,6f; No. FEE COMMONWFAIT14 OF MASSACHUSETTS Board of Health, DISPOSAL SYSTEM NSTRUCTI®N PERMIT :4 z iAlf � Permission is herebygranted to; C struct( ) Repair( Upgrade ( ) Abandon( ) an individual sewage disposal system at -� `l L-00 `0c' as described in the application for Disposal System Construction Permit No.K,-),7 dated I r? Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date l !tom Board of Health- :i� (0-