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HomeMy WebLinkAboutApp-Permit-ComplianceNo. c-4-7'7 72-/ J rL.D g, -t l --00 CoG -Z5 j 43 COMMONWEALM Of M ASSAC14USETTS FEE"`" dz4q oa Board o Health, Ade lYl 0 , MA. APPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repaii!Upgrade( ) Abandon( ) - ❑ Complete System Xhdividual Components Location �p % `'�%f'� /b' Owner's Name �' p V Map/Parcel# % � Address J���12' Lot# Telephone# 3`® e�s`f ®i ��✓®� Installer's Name V��`�®�` �% Designer's Name����/f/�. Address �..S �` /�� �y, Address Telephone# S'o ©70 ;�P- Telephone# S 6:7 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) 3� gpd Calculated design flow 9 Design flow provided gpd Plan: Date _ Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections No. _ COMMONWEALT14 OF M ASSAC14USETTS Board of Health, U -1-1i , MA. CERTIFICATE Of COMPLIANCE Description of Work: „,Individual Component(s) 0 Complete System K The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( ) has been installed in accorAance with the/ PvVi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. /7F ✓ td , dated ka —/ 7 Approved Design Flow (gpd) Installer's °'� a°�/ Designer:.✓Ji'di' �', Inspector: Date: r The issuance of this permit shall not be construed as a guara the system will function as designed. v 0'0"6L`C<J'f �t:e3.)c:;�c�OC: �O t7.COG0�>OOOOL O.O(i.p OU 000000 G00000 U0i)0000(iU000000GC 0000.UO.000VGGilGO00UOC:00GOOCiC 00000U 000.000 GOC)OOCJgO000000GO0 UC: No. W� Q r'.1-7 - Lj-72:7 - FEE . 575­1-1M---- COMMONWEALT14 Of MASSACIIUSETTS Board of Health, YtTlG.IySU u -n4 , MA. DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Permission is herebygranted to; Construct( ) RepairIN6 Upgrade( ) Abandon( ) an individual sewage disposal system at•1,147✓°-Olf�°�,1,?.�'oVti Qi6 .%'%%'�X"t as described in the application for Disposal System Construction Permit No.,Jd�tted�&- : 'f J Provided: Construction shall be completed within rttiee yearlof the date of this pe i All local c ons must be met. !�7 Form 1255 Rev: 5/96 A.M. Sulkin Co. Charlestown, MA Date/ Board of Health f 'Y