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HomeMy WebLinkAboutApp-Permit-Compliance' No. gpN-D�—V�-CVl.il /✓�/,�/ �" FEE Kr�blao COMMONWEALTH Of MASSACHUSETTS Board of Health, 1( k , MA. APPLICATION FOR OSAL SYSTEM CONSTRUCTIONCONSTRUCTICONSTRUCTIONP llIT Application fora Permit to Construct( ) `Repair upgrade O Abandon( - ❑ Complete System ndividual Components Location( ( Owner's Name XCQ,0 e Map/Parcel# Nip 5i—�_ / �1 Address Lot# Telephone# Installer's NameC Designer's Name Address {0t (/S' T fns ©Z Address Telephone# Yb9 Zy0 XO 77 Y 7 2 21 Telephone# , C � 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 providedgpd Pian: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation OF REPAIRS OR ALTERATIONS COsP�Ct<e l 1�hl I� �C�{A Slf'� The undersi grew tall th cribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr e o ace in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date _ Inspections FEE .� COMMON�LT14 OF MASSACHUSETTS � ' " `� Board of Health, I�l dl l , AM. I C, CERTIFICATE Of COMPLIANCE o� Description of Work:;/Individual Component(s) 0, Complete System p�`2 The undersigned hereby oertify that the Sewage Disposal System; Constructed ( ), Repaired), Upgraded ( ), Abandoned OF has been installed in accordance with the provisions oA310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. % 'r`�, dated Approved Design Flow (gpd) Installer Designer: Inspector: I;V,a Date: The issuance of this permit shall not be construed as a guarantee that the 6seenwill function as designed. No;���{ C -i�". tJ FAl t`�, t� Cr`�`�1 FEE COMMONWEALTH Of MASSACHUSETTS r_. -- Board of Health,MA. DISPOSAL SYSTE7)U NSTRUCTION PERMIT Permission is hereby granted to Construct/(/) Rep 'r(pgrade( ) Abandon( ) an individual sewage disposal system at ✓�� ,� ;SG �C�c�, f` as described in theapplication for Disposal System Construction Permit No. i , dated Provided: Construction shall be completed within three years of the date of this p rnlit. All local co ditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Go. Charlestown, MA Date ; a3 Board of Health