HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSACHUSETTS
No, 6O oC-I%D -Y0 q FEE 1
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Board of Health, )LAt,, oo-ni , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application fora Permit to Construct( ) Repair(upgrade O Abandon - LlComplete System 64ud��ividuat Components
Location 2
ou Sc& A ve,
Owner's Name n j)e Q
Map/Parcel# 2Z
2- 7-7
Address
Lot#
Telephone#
Installer's Name (it
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Designer's Name
Address ('�
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Address
Telephone# 5'0 6 -7,Y0 2, 0 y%222 Z�a
I Telephone#
Type of Building e
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Sbil(s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Lot Size sq. ft.
Garbage grinder { )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
Sir Ofi� C
The undersign es to inst a above rd Indi ' al r isposal System in accordance with the provisions of TITLE 5 and
further agre o to ag syste ' op e o Certificate of .Compliapce h been issued by the Board of Health.
Signed Date - 7
Inspections
No. 0 44 D L( -? C l-1 G FEE -
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 00 MA.
CERTIFICATE Of COMPLIANCE � � l�
Description of Work: U Individual Component(s) ❑ Complete System Q ,
The undersigned hereby certify that the Se ge Disposaal, System; onstructed ( ), Repaired/upgraded ( ), Abandoned ( )
by: Gt C �4 eC4 Irv/1
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer J�a i �C) Q
Designer: Inspector: _Date: 4-14
The issuance of this permit shall not be construed as a guaran00 V,$n as designed.
No. (/ ' C� ��}(. ? 1/C ! FEE j J[
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Board of Health, Y
jAA& 0i):ZV , MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repair(Upgrade( ) Abandon( ) an individual sewage disposal system
at l o z sou seC VE - as described in the application for
Disposal System Construction Permit No. / 7- dated /✓o'
i
Provided: Construction shall be completed within three years of the date of this permit. All local l�& n. i fust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA DateD Board of Health