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HomeMy WebLinkAboutApp-Permit-ComplianceNo. WJ)C4-4 S./j �Ye /" (5�,, �j COMMONWEALTH Of MASSAC14USETTS Board of Health, MA. FEE 5-5—,uu Cie%60 APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair grade( ) Abandon() - ❑ Complete System JZdividual Components Location / rr Owner's Name Map/Parcel#� i C Address 1 q -4r fp vvZie _6A ( d Lot# Telephone# wg �-g /_6 Installer's Name 't G fion Designer's Name Address 1 Address Telephone# (jam. 4-17'-006_3 Telephone# Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ No. of persons Lot Size sq. ft. _ Garbage grinder ( ) Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date % Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator 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 agreer o n t place the=mm tion until a Certificate of Compliance has been issued by the Board of health. Signed , Date it —It—ug Inspections No. 6Q kAy A(0 ` . 31 l 'A E V COMMONWEALTH OF MASSACHUSETTS J Ilk r� a4`a� Board of Health, Ywr-, MA. b`� XQ\ A �EI�TIEI�ATE ©�®MEEIAN�E Description of Work: XIndividual Component(s) ❑ Complete System The unAersi d h eby certify that the Sewage Disposal System; Constructed ( ), Repaired �•�graded ( ), Abandoned ( ) by 1 b �"iC•Cl`�1f:Zi I o�1 ij at PA , \1 has been installe in accordance with the }�rovisio s of 0 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to applicat r__Vo. 14 —j -,W-10 ,,dated /.✓ 1� � Approved Design Flow s (gpd) Installer U i Designer: Inspector: C WIEW Date: 11-17 P The issuance of this permit shall not be construed as a guar ' ee that the system will function as designed. U OOOJOOOOUOUJ Gi;JU..c OCUU�i)UJ OObUJUOU CUc?JOOUi)JOJOO CU OJO_J:)UUiSU OciOQ_J (JO Uv'U OC ^vU OC UO UCiJG C�'ll0 'CGG:,n G.ICCJ'O JO:Y.0 O.. :, (:.:,i _ _ _.___.._ _... C. t f �j 1 No. 0 C -IG-1531 `„f FEE 5 C)Q COMMONWEALTH OF MASSACHUSETTS Board of Health, iArtzoank , MA. DISE®SAI. SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( �), Repaizr(,�pgrade( ) Abandon(�an individual sewage disposal system at t ``"' �r t �#- S, t/ C t el 1� l CA 3 !1 Y1 r described in the application for Disposal System Construction Permit No. i� '�, da�1ted�t Provided: Construction shall be completed within -three ye�dY Sof tZ date of this perm; . 1 local co itions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date(// .1� ,, pard of Health ci �, i