HomeMy WebLinkAboutApp-Permit-ComplianceNo. O1Uc--("Z8o
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80TH- 17- e o) 3 y8
COMMONWEALTH OF MASS C14USETTS
FEE E,5+ ESC%
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Board of Health, �{Z X1/1 d l�'%-� , MA.�,
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'emit
CATION FOR.1DISPOSAL SYSTEM CONSTRUCTION PERI IT
pl cation fConstruct() Repair() Upgrade bandon() - El Complete Systemividual Components
Location ero rr- w e'l N-
Owner's Name L' (uw-ei %
Map/Parcel# r�s
Address q jej,.p-
Lot# 2,&
Telephone# Sp ?--,3(0 Z - X32 2 -
Installer's
Installer's Name 90 ,�- o - ht°
Designer's Name gy,,,J*S ie,w-r j -E yl
Address bre'- n w, cl,
Address f o. jl 3 F, I veAnt5 At -4-,
Telephone# 1 D1`-, o - �
Telephone# Jo? -3 (y
Type of Building i ue I (oj Lot Size Q_ sq. ft.
Dwelling - No. of Bedrooms �'% Garbage grinder( )
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) �/i7 gpd Calculated design flow 1 *9 Design flow provided gpd
Plan: Date q- �i" J(o Number of sheets Revision Date
Title `7 (moi 0 ril
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONSsp
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 agrees to not t plac thesys��tem in� operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Afk)-r" 4$-9V Date !�'l6
(- — " S
f Inspections /�' I b UL(_ �� S t� / c
l tK `f C. 1tCC t tv t sc�-L
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No. _ � o$ (V 02-9 0 FEE �?
COMMONWEALTH OF MASSACHUSETBA L+ CA* 0015(, t
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Descnption`of Work: ' Individual Component(s) C3 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Vr, Upgraded ( ), AbandonedO
by:, P,0 13, 00 r to. rn e—
at K C(� rYL W ey 1 1) p -
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and th a proved design plans/as-built plans relating .to
application No. dated Approved Design Flow (gpd)
Installer K.,n 1wrT S, ou r 6,)- .:t N C C` 1+R- STZ) P k ep- t) 0 R..4
Designer:X5555 o Lk;- Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. &ODC - 16"02,?0 R . e) . ooa- co. FEE
/ --> � / COMMONWEALTH OF MASSACHUSETTS c.* 0o -75Z I
Board t f Health, proZ.P ou-m MA.
DISPOSAL SYSTEM CONSTRUCT16N PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade,(,. —Abandon ( ) an individual sewage disposal systefii
at t^r s'rn U)"'lf as described in the application for
Disposal System Construction Permit No.dated
I
Provided: Construction shall be completed within tlax �f� It ie ate of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown MA Date �" " ' i''--6%pard off Health ;Oc�-1/ d
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