HomeMy WebLinkAboutApp-Permit-ComplianceNo. �-, •• Vo 4130 J l l , FEE - V `i
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COMMONWEALTH Of MASSACHUSETTS
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Board of Health, �� ®� l MA.
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4A LIC ®N R DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT
aion( p ' •() Pg () P ys Pcation for a P r ,t to nstruct Re an U rade Abandon - I�COm Tete System El Components
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Owner's Name ✓
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ap/Parcel# 7 7 g
Address
focation
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Telephone#
staller's Name �� v,r,�O
Designer's Name
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Address 1072 C/
IG Address
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Telephone#b $
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min, required), gpd Calculated design flow
Plan: Date //" 3 /e, Number of sheets
Title
Description of Soils)
Lot Size sq. ft.
11
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided J 67, s gpd
Revision Date
Soil Evaluator Form No. V Name of Soil Evaluator 1%'. '_4Q 4 �/CY ( 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 too no�ce th�operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date / d — Z_ 1/
llleirke!
Inspections !L- A4 YC X11;
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No. j;. `�(o" t �s� /+• , �` FEE•.-
�COMM®N�ITII Of MASSACHUSETTS �'' ,14
Board of Health, �Yi�7��1 t� MA.,;?
CERTIFICATE Of COMPLIANCE � a,� �V-01
Description of Work: Ll Individual Component(s) kComplete System
The undersigned hereby certify�tf,at the Sewage Disposal
System- Constructed ( ), Repaired ( ), Upgraded ( )> Abandoned ( )
by: � S
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has been installed ' L accordance with the provisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. i'� dated, e-- Approved Design Flow ' t (gpd)
Installer
Designer:r:+t.. i_ f if l /• 1'Inspector: r/ � Date:
The issuance of this permit shall not be construed as a guaran ' e that the system will function as designed.
No. ?4tt t.7 C C)17�,e i , FEE `~;`'b CX 1
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �'�Oii di Vl _ , MA•
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade. Abandon ( ) an individual sewage disposal system,
at L -f 9 a rt_ _ _ _ as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within tl '�tf the date of this perpijt.l Xl local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown MA Date/2- Board of Health
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