HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, ). �, CA7T,-RMA.
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eA,t-6553
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
ra Per t to Aonstt ct( Repair( ) Upgrade( ) Abandon( ❑ Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
Address
`fQ,
Lot#
Telephone# (" 17 �- �, � �
7
Installer's Name '
Designer's Name e� �
Address
Address
4
'
Telephone# _ 0
III
Telephone#
(CJ ` 7-Y —t � j]�7
fpe of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( }
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixturesv
Design Flow (min. re uired ��L1 gpd Calculated design flow q Design flow provided _� gpd
Plait: Date % Number of sheets I Revision Date [ - :.R_q^ 1
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS J 4-01 &4-7
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Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree of to pla a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ' ! Date z
Inspections173�{t�
II� f R—is
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No. ,{^h r� �p "V �� �T A"I, ! SEE �,,
COMMONWEALTH Of I�'I SSACIIUS�ETT� JL4`555
555 "
Board of Health, , MA. 0-4' �l' `Dt 411,
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CERTIFICA19 Of COMPLIANCE lle66
Description of Work: ❑ Individual Component(s) Complete System j,/ e��
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( bandoned
at
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. -, datedApproved Design Flow-�(gpd)
Installer a, k I 'gas L\ 12-u? i5
Designer: r,', S&Q C- a Q,, n Inspector: J Date:
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
COMMONWEALTH OF MASSAC14USETTS
Board of Health, AO � f MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE 00_ _
Permission is hereby granted to; Construct Repair( ) Upgrade�kbandon ( ) an individual sewage disposal system
at (0 :14 N�Q , as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within tl ea� bf tFie ate of this peri i .. local conditi s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, q Date � � (-`Board of Health f' , �`r^�"
"f r ..1 / i, � �_ .,fir /�/!' f ! —Jk' w/�s , - - / - V,,zt,,4IA /l ss.