HomeMy WebLinkAboutApp-Permit-ComplianceNo. k7o VG'!6— %r" rV�e &-b "I v oo6vto FEE c� �
�® MONWEALTH OF MASSAC��TSETTS Cg 5-12.
orad of Health, li/10 i1' j , MA.
PERMIT
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Application or a Permit (o C�oynstrue ) Rep ir( ) Upgrade(✓<Abandon ( - U -Complete System U Individual ComponentsU.
Location
Owner's Name
Map/Parcel# 1{
Address
Lot#
Telephone# foe I — --;L,3
Installer's Name 1 �.
Designer's Name.
Address /
Address 3
Telephone# — �
Telephone#
Type of Building Lot Size sq. ft.
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 Design flow provided
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) 64Zg 4a -
Soil Evaluator Form No. 0 Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 op on until a Certificate of C m fiance has been issued by the Board of Health.
Signed Date (1P_
Inspections
'16
No.
COMMONWEALTH OF MASS CH S ETT 4�1
Board of Health, )(Azure) t, i MA..4
C ERS 1CATE Of COMPLIANCE
Description of Work; ❑ Individual Component(s) J2,C"o,mplete System
The undersigned hereby certify that the Sewage Disposal System;+' qtitftjcted ( ), Repaired (
sr
YEE
16
by: , '
at r01g
has been installC'YlYh •cord e p visions of 310 C1 IKi KL�pe 5) and t e approved design plans/as-built plans relating to
application No. / ° dated Approved Design Flow d)
Installer
Designer: SILE-C- Inspector:i' Date: r! �� •�(�
The issuance of this permit shall not be construed as a gua tee that the system will unction as designed.
No. �aC�t„ ��! Imo' PU? �.C� 1�` '� �'�li�v";l�r FEEy
7 COMMONWEALTH OF MASSACHUSETTS cei 9 2 --
Board of Health, V&ejA0j j , MA.
DISPOSAr SYSAM CONSTRUCTION PERMIT
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 tLSLXe-,4xsof the date of this per it. All local condi 'ons must be met.
Form 12555 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA / Date/`^ /' / BPar O ealth
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