HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
�OMMONWEALTH Off' MASSACHUSETTS a8 �7
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41�49" Board ofFlealth, %1't1E�� , MA. c
r�APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgradej Abandon( 5C1mplete System O Individual Components
Location %D t
Owner's Name Q c t r(
Map/Parcel# 119-131
Address 6) Moo
Lot#
Telephone# d
Installer's Name Qr�
Designer's Name
Address(
&®
Address O� +-e
Telephone#
1 Telephone# e • taq=_
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms �19 Garbage grinder
Other -Type of Building No. of persons Showers ( ),'Cafeteria
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s) ,-tLgZ_e2_dCeyh4
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
I
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersi ed agrees to install the above described Individual Sewage' Disposal System in accordance with the provisions of Tr= 5 and
further agref to not toa the tem in operation until a Certificate of om�1i �c as been issued by the Board of Health..
Signed � Date
Inspections
COMMONWEALT14®f MASSACHUSETTS
f
Board of Health, oo7v 1111'M.
CERTIFICATE OfCOMP IANCE
•
Description of Work: ❑ Individual Component(s) 'Complete System i
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded f( Abandoned(
by:
at f`1
has been installed i accordance with the provisions of 3 0 CM X15,00 (Title 5) and the proved design plans/as-built plans relating to
application No. S _, dated :r % % Approved D gn Flow lZ(gpd)
Installer r
Designer:
inspector.,. J
Date
The issuance of this permit shall not be construed as a guaranSee that th system titirtsIdesigned.
No.1:? <, t. - L (v t > ^t" 'LC�q +� Yi FEE....i .. 00
COMMONWEALTH OF MASSACHUSETTS J�_ C,
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
,9
at as described in the application for
Disposal System Construction Permit No. 125--!f, dated ':I �' 11.
Provided: Construction shall completed wit thr of the date of thts permit' All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co: Chalestown,MA D•attsz + Board of Health
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