HomeMy WebLinkAboutApp-Permit-Compliance-10?3No. Bo H-PC'1 / FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT 5 Ll
Application for a Permit to Construct( ) Repair( ) Upgrade�AbandonO - ❑ Complete System �'1"ndividual Components
Location � ILI
C)ID �}�. % � �..-..��
Owner's Name
Map/Parcel#
' GU y
Address I y y l t'11 -%,h
Lot#
Telephone# SC, dL [q Lj y �'
Installer's Name r t j 1 D-4 CX4401
Designer's Name A S G 6
Address a
jZ n jev
Address 3q ac,,.v
Telephone#
J-0� 3AL &A3 71
Telephone# �7
Type of Building 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) -07� gpd Calculated design flow __ , i Design flow provided gpd
Plan: Date y"I Oiaq-e,/,Number of sheets Revision Date
Title ��
Description of Soil (s) ! �-" Soi'i 10�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Ci'_Cod-�`-
The undersigned agr to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to pl a the s to o ntil a Certificate
Compliance has been issued by the Board of Health.
Signed Date — 3
< , Inspections
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COMMONWEALTH OF MASSACH*U
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Cl.%fi'dividual Component(s) Ll Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded 4, 4 andoned ( )
by: r Z l I.S n I'n 31.90 J
at ) t-1 01 i3 1�0 6,e) S3f't- r' } 130" Th :� in r w Y'1 + Gl
has been installed in accorda e with the provisions of 310 CMR 15.00 (TiT 5) and thea proved design plans/as-built plans relating to
application No , dated. Approved Design Flow (gpd)
Installer I l:! i� f2st -I) P-tLAA 11,4
t
Designer: S {^Co ??Ci j , Inspector: Date: _
The issuance of this permit slfall not be construed as a guaranteyat the system will function as designed.
114
COMMONWEALTH OF MASSACHUSET TIS
Board (f Health,y J1M 01 nj o , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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FEE C-0
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Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at I i Li O ) t^ 1 ct i'rZ r -e oLx 6- r" C-1 1 M as described in the application for
Disposal System Construction Permit No. '" dated 7
Provided: Construction shall be completed within ljllro�the date of this permit. All local cWdidons must be met.
Form 1255 Rev, 5/95 A.M. Sulkin Co: Charlestown, Mn Date Board of Health
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