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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ��'� C.-'� 6"��C { � ��� ��Ll �L�- 1 � �". L.P � � � �i•,�ll,� ��G - ''E �/ ��co►s�- fZ�t�379' 16 C® ® LT14 Of MASSACHNTT ,. Board of Health, X11,11 , MA. c APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION �-N�.1"� Application for a Permit to Construct( ) Repair( ) Upgradee)Abandon() - .Id Complete System O Individual Components Location C'Z' pv/ h r Owner's Name .d , Map/Parcel# l G Address Lot# Telephone# Installer's Name Lf Designer's NameVj Address l,7— Address Telephone# __!�0 Telephone, Type of Building �l/� r 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) If d gpd Calculated design flow 3 3 o Design flow p. Plan: DateNumber of sheets Revision Date _ Title Description of Soil (s) _ Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS -S PA --!Z Date of Evaluation gpd The undersiggedItgrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr n to lac th tem in operation until a Certificate of C mp iance has been issued by the Board of Health. Signed Date % Inspections . .. .. .ice .. _ ✓.;. ZFEE No...' J` COMMONWEALTH Of MASSACHUSETTS s* 1Z( -c -r -#i-- 3-76 Board of Health., lull © LM+ _ ; MA. CERTIFICATE Of COMPLIANCE Description of Work: 0 Individual Component(s) OrComplete System y at the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ) hereby c ruf th p ' O, pg Sjt�, Abandoned b9e yhe undeG_' at has been installed i actor. an e with the provisions f 3�.0 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to application No. / r'f ..?, dated (i> �' '�—Approved Design Flow �(gPd) Installer o (c a E - / / Designer: -'Dt)uN �CAC- � t`) e I-JCF�f13rInspector: k,/lf 1 L Date: d ✓ I The issuance of this permit shall not be construed as a guar tee that the system will function as designed. aoe�0000,aC,0a0oC).o .I O'_ .o 00a„r.-:r (/ No.��`�D��1+"�Q��.-t YI1�)C7 FEES `� " / —> :!,1COMMON LTH Of MASSACHUSETTS ci Board of Health, �2&0079 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; nstrruct( ) Repair( ) Upgrade (jO' Abandon ( ) an individual sewage disposal system at , cif C�7 'v'""��✓Cr'S '/ 's G' / / as described in .the application for Disposal System Construction Permit No. �� ~% +dated Provided: Construction shall be completed within th-ree-YeTrVoT the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date 16 /- //2(' Board o Healt 7,::.yc % j f/l�