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HomeMy WebLinkAboutApp-Permit-ComplianceNo. �7�5�V�oZZ 501Truer1 (6 — VV5'17(o „ Xk / ,; 06_14W V, FEE /�--,F-7 C®NIM[® I.F MASSACHUSETTS c�a� 12g Board of Health,y �%'j0(ZW , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(K) Upgrade( ) Abandon() - ❑ Complete System ad'Individual Components Location �53 OLD TDL,,)Q j'- f Q_<C- C> Owner's Name Map/Parcel# a © Address KI Lot# Telephone# Installer's Name (2A-Putt.xo G -T (. Designer's Name Address l53 0U.(U4Q_0_1, -_ST M�1065 Address i,,- ckaS Telephone# 569 -4-7-7- 2217 Telephone# '' -q-'71 - 5-3 -t Type of Building IzGSto t A -L_ Lot Size 9 , 500 — sq. ft. Dwelling - No. of Bedrooms y Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 4 4 C gpd Calculated design flow Design flow provided 142 -7 3_ gpd Plan: Date 5 2 ^ / (, Number of sheets oZ Revision Date Title Description of Soil(s) _ tt Soil Evaluator Form No. Name of Soil Evaluator R P`CEA:TI_--C-�' Date of Evaluation q ` X -j -'10116 DESCRIPTION OF REPAIRS ORALTERATIONS U5C= GKI S7l0 Ea 1,,oyy 6ok% tV EW 1 5bb 6%0 . _4�Epp-t-tl -W-[eK _rb "61U b- F�aK -ro (I L --Or - Cc 4&?!k-At,06r ClueAaL Lut2j;j hr The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Al C Date 2- -ao l/ Inspections No. FEE `TS, 00 COMM ONWLAI.TII OF MASSACHUSETTS Board of Health, 119 Lit Inn , MA. CERTIFICATE Of COMPLIANCE Description of Work: oRrIndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.(►', Abandoned ( ) by: C' �+4P�c.c>►� div t P��� LAG at moose- kDAi> has been installed in a d d c' with the ProAsions of 310 CMR 15.00 (Title 5) and the &proved design plans/as-built plans relating to application No. / 1 , dated Approved Design Flow"1gpd) Installer CaPEe.)tiZ_ Etv'? U -X- "� 1 !') zt�?2_OV�1t'Y Designer: C_4JW0,4___ C.dk6 WQi s Inspector:_ Date: -6 f % The issuance of this permit shall not be construed as a guarade. that the system will function as designed. :)0000000000000 0000 o ooco, o oo0 cC00:'Go coC,00C1U',li,P"00oa00000oc C]C_..obo 0000OJ 0 ,L a003OL`COt?c.U?OGi On-(�Op,p�?n•J0-f)'Ec3-[-rC-'OOOOJO,.��C`V:>Ot, G00117o V�'f?C No. I; :�? kAW_ We � -D �_- FEE S - S-- CIO /� — 9 % COMMONWEALTH LTH ®E M ASSAC14USETTS ck=i� -3c.� I Z b Board of Health, MA. DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Permission is herebygranted to; Construct( ) Repair( ) UpgradeAbandon( ) an individual sewage disposal system at as described in the application for "-��� d Disposal System Construction Permit No. atedJJ� Provided: Constr ction shall be co pleted v; th��"s-? � e date of this per, it. All local conditio must be met. Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date r .r/ -hoard of Health