HomeMy WebLinkAboutApp-Permit-ComplianceNo -0 0 Vk-D C- f 8-3103 D L bTQ - i $ -606 466
COMMONWEALTH OF MASSACHUSETTS
FEE $ E55- 00
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Board ofHealth, YARMD L) -Iv MA.
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APPLICATION FOP, DISPOSAL SY EM CONSTRUCTION PE MIT
Application for a Permit to Construct( ) Repair( ) UpgradeAbandon() Q Complete System Individual Components
Location
1
Owner's Name
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Map/Parcel#4,,�7
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Address
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Lot#
Telephone#
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Installer's Name
Designer's Name )�Adl
AddressY
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Address I
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Telephone#
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I Telephone#
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Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building —
No. of persons
Lot Size n// s, ft.
Garbage grinder
Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. reqgpd Calculated design flow Design flow provided gpd
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Plan: Date d -111k Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agryf iq install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to-alfft e the temyi puntil a Certificate ;Aonplian:e�been issued by the Board of Health.
Signed Date
. Inspections
No.' -t FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, YMM004 MA.
CERTIFICATE Of COMPLIANCE
Description of Work: w6gwdualComponent(s) Q Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed(
by:
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has been install
application No.
Installer
Upgraded 44-,-fiandcin,d
with thlo 0 Ca d 15.00 (Title 5) athe prove design a d d ign plans/as-built plans relating to
D
dated Approved Design Flow 3 (gpd)
Designer: 1� ki I- -F-F,
1
11 61, IL Inspector: r v t,4- Date:
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The issuance of this permit sh
not be construed as a guajpZe that the system will function as designed.
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No.
FEE
COMMONWEALTH Of MASSACHUSETTS
Boarqf Health, AM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT 4,
Permission is hereby granted to; Construct Repair Upgrade ( -Abandon( an individual sewage disposal system
as described in the application for
at 'I ee 64 e4
Disposal System Construction Permi-No. ated
Pr6-Med: Construction shall becornDleted withiri-t*r6ee4& the date of this De n*- . W1 local cond1t10j-1-%must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date 1 .1/ C /, Board of Health
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