HomeMy WebLinkAboutApp-Permit-ComplianceNo. �J�tS�C- I� V FEE' V lit
COMMONWEALTH OF MASSACHUSETTS d y 657
Board of Health, i QiNI tJ Ted MA.
APPLICATION FOR D IS OSAL SYSTEM CONSTRUCTION P - MIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon O ❑ Complete System Individual Components
Location
Owner's Name . q o e Akc
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name
Q c C- 4 l� S PC
Designer's Name
Address
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Address
Telephone#
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Telephone#
Type of Building /t e Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers O, Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow providedgpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS Te5ecd —
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Date of Evaluation
The under gn a st o described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ee ace the in operation until a Certificate of Compliaf� has been issued by the Board of Health.
Signed Date � Z - j/- ( r
COMMONWEALTH Of MASSACHUSETTS
Board of Health, _TVA_, MA.
FEE 1`.100
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CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned herebycerti y that the Sewage Disposal System; Cpnstructed O, Repaired Upgraded ( ), Abandoned ( )
I i)A
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. Ikr, dated i _l�� Approved Design Flow (gpd)
Installer i� Ct_C f f (_ i. �'! C,
Designer-: --- Inspector: Date: ,�aG'• '`�
The issuance of this permit shall not be construed as a,guapi6ee that the system will function as designed.
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No. o 4 4 it - S-,D ` FEE
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� `_> COMMON LTA Of MASSACHUSETTS
Board of Health, ��o (Mi , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby ranted to; Construct( ) Repair(/Upgrade( ) Abandon( ) an individual sewage disposal system
i . as described in. the application for
Disposal System Construction Permit No. / / ' , dated If
Provided: Construction shall be completed within three years of the date of t=,,'L,
percal conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date I 7 Board of Health / t