HomeMy WebLinkAboutApp-Permit-Compliance. Aro. OWC ^ 1-7-379Z., / FEE ' 56"00
17-0 COMMONWEALTH OF MASSACHUSETTS 447A5q
Board of Health, _ tagmom, MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrad Abandon( ) - SComplete System 0 Individual Components
Location
Cllr Y- 1201' A b- L(% 61
Owner's Name
Map/Parcel
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Address �M-Halo--.&a
Lot#
Telephone#
Installer's Name
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Designer's Name :ZS` C;)tQ,2, A -h
Address
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Address `s, d� L -72 q 5A #jd % J L H
Telephone#
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Telephone# 5-0-0-5-0-7-3600-Z!�4 AI
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Type of Building �• /�' % /� ih f L✓ /� Lot Size � � sq. ft.
Dwelling - No. of Bedrooms Garbage grinder (AI�2
Other - Type of Building No. of persons Showers( ), Cafeteria
Other Fixtures
Design Flow (min. _(.� — gpd Calculated design flow —Z� Design flow provided gpd
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Plan: Date ""'log—`G Number of sheets O?� Revision Date
Title
Description of Soil (s) -Z
Soil Evaluator Form No.
,17z � V,
DESCRIPTION OF REPAIRS OR ALTERATIONS
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pie Soil Evaluator
'tee 7 7/�,7s/
Date of Evaluation /,/`� G G
The undersigned afire to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to pl a th sys e o eration until a Certificate of Compliance has been issued by the Board of Health.
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Signed �� - Date ~1
Inspections
No. � i �i �_ "i ! " �• (/ �1�� FEE �D .°i . 06''
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA. 1`1/'
CERTIFICATECERTIFICATEOf COMPLIANCE
Description of Work: 0 Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( )Appgraded ( ), Abandoned ( )
by::�
has been installed in accordapce with the provisions of 310 CMR 15.00(5) and the tpproved design plans/as-built plans relating to
application No. /— dated Approved Des n Flow �(gpd)
Installer I% 5 . C
3
Designer: A' Inspector: Date:
The issuance of this permit shall not be cons ued as a guarantg that the system will function as designed.
No. �- ti I ' J�a• FEE, 3 6J
-
COMMONWEALTH ®ISSCUSETTS
Board of Health, VJW-- 1A( [ID4 , MA.
�.. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade{ Abandon( _) an individual sewage disposal system
at` '" ,✓ (' 1.�,✓ /Z v ,19 ,t�' )a � �l �lj A,W I.flr/- �i as described in the application for
d
Disposal System Construction Permit No. / , dated --i7
Provided: Construction shall be completed within three years of the date of this permit AI local�l conditiorismust be met.
Form 1255 Rev. 5/96 A . S Ikin Co. Charlestown, MA Date '?Board of Health C.L✓-d'
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