HomeMy WebLinkAboutApp-Permit-ComplianceNo. fi f j' Do /TG FEE a00
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ` o0' -, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( - e Complete System ❑ Individual Components
Location U*
Owner's Name
Map/Parcel#Z ,
Address /�
Lot#
Telephone#
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Installer's Name
Designer's Name
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Address A3 CZ vti j�
Address �, 7
Telephone# cLqt C-0
Telephone#
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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) gpd Calculated design flow Design flow provided — z�_ gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils) S4
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S
The undersigned agrp4s to -install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t to e t til a Cert ficate of Com fiance has been ' ued by the Board of Health.
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Signed Date
-4 = Inspections
No. I FEE J �U
Board of Health, YAjn LJ f 4 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: =JQ Individual Component(s) omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned ( )
at ! t GAP i� n..s^ —✓° %, ,\ i', !`•�.%`�,� V C J!1 i. -F:. :.r`.-�: / *..
has been installed inlaccor an�jth the rovzs ons of10 CMR 15.00 (itle 5) and the roved design plans/as-built plans relating td;
application No. f' > ,`-d'ated j� j Approved Design Flow -I" (gpd)
Installer d_ t i4' i '
(A. ;%� �; i,\-- Ins ector: Date: /
Designer: f ` i `� p —
cz ell
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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/7-2-40 C®MMON LTIT. OIC SSAC14USETTS c =
Board of Health,' YAOJO (YT -4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebyranted to; Construct Repair( Upgrade � ) Abandon an individual sewage disposal g ( ) p ( ) Pg .�'( system
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at as described in the application for
Disposal System Construction Permit No. ,� 2- (,dated % .
Provided: Construction shall be completed withityjhre�-� arr`� of the date of this permit.01 local con ' 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown MA Date _ �� i Board of Health