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HomeMy WebLinkAboutApp-Permit-ComplianceM, a I No. 170DC�CL"t�1�j✓ ��+ j� 1yu 400 �(f�� � � �6/�- / �b���✓ 1.� L b � I _FEE OMMONWEALTH OF MASSACHUSETTS Board of Health., , MA. A PjPfi 'ATION fOR DNPOW, SYN- I[ CONSTRUCTION PERMIT plication for a Permit to Construct( ) Repair(( Upgrade() Abandon( ) - ❑ Complete System ❑ Individual Components Location a E>yjn Owner's Name Map/Parcel# 9 13 Address "17C) ov Lot# A4 9 Telephone# Installer's Name C,Q „a 0 0 Designer's Name a AddressAddress e ar o Telephone# G Telephone#,Tog• 3G a 'i4,S q% Type of Building RSx4r- -1 cx- t Lot Size 13. 000 sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) .330 gpd Calculated design flow �� Design flow provided gpd Plan: Date %O%'1 IS 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 ALTERATIONSTJ�if�i%� QaX - 21'11 i )-)1'c�'� O T' S 6L: ) 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 system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date • Z� • 1. Inspections No.��`1(O"%� C®MMONWEAI.TII OF MASSACHUSETTS,, Board ofHealth, u- , MA. CERTIFICATE Of COMPLIANCE .10� A Description of Work: ❑ Individual Component(s) 'Complete System //4P& The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded ( ), Abandoned ( ) by: -8 X Ca V CI at 0 ©O-! o� o n d 5 .fl has been installed to accor ance' ith t e''p o -v ons o 310 CMR 15.00 (Title 5) and tproved design plans/as-built plans relating to application No. 6' o"he dated �� �ryry Approved Design Flow (gpd�,,e Installer• xe:� �a o f rC'l G. t« _ <.i �! _ ��1-v'w J � Designer: —Doto r\ Oa p e` E NJ& Inspector: _ Date: The issuance of this permit shall not be construed as a guarankee that the system will function as designed. 0'..0 .. �D �_crv_�o..�,, �.. :o10..+ ^ 1 mac:-,�....o, .. ` No. 1Vfj"'-I� -rJ"li �'� �.:;�-i�:l� 1�.X�!�rti (`*� FEE � `�� COMMONWEALTH Of MASSACHUSETTS � � 7 0-7 Board of Health, I A am O t -rw DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) ReP 'air(4 Upgrade( ) Abandon( ) an individual sewage disposal system at O Our) cK' Bour�,A -S D7 - Q r-// as described in the application for �Disposal System Construction Permit No. , dated —/— k . —7 Provided: Construction shall be completed within thtee-peafrof the date of this permit, All local conditions must be met. Form 1255 ev. 5/96 A.M. Sulkin Co. Charlestown, MA Date ! ��/ Bea d-oHealth_ i%,�