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HomeMy WebLinkAboutApp-Permit-ComplianceNo. Li1-7 � / ✓ FEE S29 00 z C,Ge&-2S 8 � � MM®NWEAI.TII OF MASSACHUSETTS Zef oard o Health Ol MA. A�1t� s APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(VrRepair( ) Upgrade (4/Abandon ( ) - ❑ Complete System VIndividual Components Location 3o O� L Owner's Name Map/Parcel# v Address 30 01,0 S i Lot# �.- 02 Telephone#IF Installer's Name Designer's Name AddressAddress fJ� ® 0 ' Telephone# -4 -Or Telephone# CI-op Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures No. of persons Lot Size Y4 %ol O .,$- sq. ft. Garbage grinder Showers ( ), Cafeteria ( ) Design Flow (min. required) 1/0 gpd Calculated design flow -3-30 Design flow provided ��i.S % G c7 gpd Plan: Date % -- rf -- Z 6 Number of sheets Revision Date Title Description ofSoil(s) O Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS V. Name of Soil Evaluator / �,- �,__D 62 -12,6-C.2 of Evaluation / 45- 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 placeth system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed _ �� _ t, Date L.. Inspections .-e arc I No. -6t).0 b r " �h -(} i % d +4C{7c �• �/E 00 COMMONWEALTH ®F MASSACHUSETTS p, _ Q' Board of Health, �2R� ITI F , MA. OIL I3f. —/c 6 d� /;=` �J CERTIFICATE' ©f COMPLIANCE VY -Y Description of Work: W4ndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed , Repaired ( ), Upgraded (Abandoned ( ) by: at < ,'� �'s i ✓7 T i c %r.��g/ 4� 1 r PFJ_ f � has been installed in accordance with the provisions of 3f10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. Y rdated b. Approved Design Flow . ,5" 1 (gpd) i Installer .G i -fid. = 1 C I j ! CT— st Designer: Inspector: .' jr� i '` Date: .: f " The issuance of this permit shall not be construed as a guarantee that the system will function as designed. 0C 001 OO -71 � �.���--- � FEE S'" e", ;.�4.. �s 4 COMMONWEALTH Of MASSACHUSETTS � � e, a Board of Health, DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(vf Repair( ) Upgrade(VAbandon( ) an individual sewage disposal system at n r?t. �" i d "a4-6 '? o , as described in the application for Disposal System Construction Permit No. / f ,dated ' Provided: Construction shall be completed within three yeafs of the date of/this p it# All,local'4eonndipgns,must be: met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health 1 f l