HomeMy WebLinkAboutApp-Permit-ComplianceNo. Bob- ���SF�-0� l�1 �O�✓� /1- •�-CCx. ��L .l 1 �/7C� � ��. ���C,�I�°�
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �Alj. , .0OT" , MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(t►Repair() raode( ) Abandon() - ❑ Complete System ❑ Individual Components
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Location f
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Owner's Name
Map/Parcel#
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Address UM /'Z! ° 5
Lot#
Telephone#
Installer's Name
J!!V Designer's Name a&_X
Address 3
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t ddressem lL
Telephone#
Telephone# . `
Type of Building CZ ./ U'J a / ea��/ ✓ 4 �i(///�%`P/�i�(iSCL /✓�7 ��-40,ot Size &J., V`� ft.
Dwelling - No. of Bedrooms % ,;7 4 SCV S/ 7 �DGI� �/�e/ Garbage grinder ( )
Other - Type of Building / No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. r quire .)wry �� gpd Calculated design flow Design flow provided gpd
Plan: Date 0110 --god Number of sheets Revision Date
Title ��
Description of Suil(s) -
Soil Evaluator Form No. Name of Soil F
j)X00 F00Date of Evaluation
The unde ' ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afiree t o la1he cyst m ' eration until a Certificate of n li c ha been issued by the Board of Health.
Signed Date f 0
Inspections
Description of Work: 0
The undersi ned,hereby
by: J`" )
at % 1,
has been installed�ti6_�,
Installer
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_. FEE Q QU
��MM'� � �T OF MASSACHUSETTS
Board of Health, yP gM O Vn4 , MA.
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CERTIFICATE Of COMPLIANCE
Via Component -ti) W'Compiete System
;hagthe 44ge Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
Ah�the provisions of 310 CMR 115.0'0 (Tittle 5) andtith'e approved design plans/as built plans relating to
dated - — . Approved Design Flow 7(gPd)
Designer)AffWP( k1( PY' s I^fA1,41 114 0 Inspector: J__j
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. t6, l PC- G. f` XFEE 10. 06)
COMMONWLALT14 Of MASSACHUSETTS
Board of Health, YA R I V- - , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Con
at 1,27 llf )d l f
Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. /¢ dated
Provided: Construction shall be completed within three years of the date of this permit.local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date %Z -/ Board of Health