HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60ADC 1.7
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COMMONWEALTH Of MASSACHUSETTS
FEE
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Board of Health, � VMQ l l� MA. OvAl
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APPLICATION FOPD POSAL SYSTEM CONSTRUCTIVdwidual
�RMIT
Application for a Permit to Construct( ) Repair ) UpgradeO Abandon O - LJ Complete System Components
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Location WI /
Owner's Name
Map/Parcel# o
Skddress
Lot#
Telephone#cD�
Installer's NameZ e
Designer's Name
0
Address ? A7 /�K Gln
Address
CIO
7X2>,�t?7
Telephone# 4EZp
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers( ), Cafeteria ( )
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
NAQ of Soil Evaluator
17 _/
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 to not o lace syste ' operation until a Certificate of Complia a has been issued by the Board of Health.
Signed Date
Inspections
No. e>00 O�r1�' Z / /`eE
COMMONWEALTH OF
i>t
Beard of Health, , MA.
Aelaap allar
CERTIFICATE OF COMPLIANCE &
Description of Work: Individual Component(s) ❑ Complete System S ®'
The undersigned hereby certify that the Sewage Disposa�ystem; Constructed ( ),Repaired, Uplgraded ( ),Abandoned ( )
by:
at
has been installed in
application No. 1-7
Installer
with the prov1si&s of 310 CMR 15.00 (Ttfle 5) and the approved
dated el`ld' �~'I Approved Design Flow (gpd)
plans relating to
Designer: Inspector: Date: r�
The issuance of this permit shall not be construed as a guaran that the system will function as designed.
No. Ypnkl Dc- 4 Dfin�-3 FEE �r
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, V ,i1i1 01-j-4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( �jUpgrade(( )Abandon ( ) an individual sewage disposal system
at o lJ -'I as described to the application for
Disposal System Construction Permit No./dajted�
Provided: Construction shall be completed within Lee.varso thate of this permit. All local condauld9ps must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date '.�� pard of Health