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HomeMy WebLinkAboutApp-Permit-ComplianceNo. EEE COMMONWEALTH OF MASSACHUSETTS &-t? 788 Board of health, , MA. L C ION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( .) Upgrade( ) Abandon( - ❑ Complete System 0 Individual Components. Location Id 9 Se -4 ie e Owner's Name �9fiSso Map/Parcel# S' Address axjGf r 7� �r�4 S 1GiIlG Lot# 7.3 Telephone# Installer's Name �` u- L r dui , • Designer's Name , Address i ,..I� 'Po ox Vey /�f'�aU �. Address 9y f�a�ia� S -ter Telephone# X6&6' -771,-6V,60 Telephone# O . 41sal % Type of Building k/siae h,4, Lot Size 7 4� sq. ft. Dwelling - No. of Bedrooms Garbage grinder { Other - Type of Building No. of persons Showers O,'Cafeteria ( ) Other Fixtures Design Flow (min, required) T56 gpd Calculated design flow 3 yG. Design flow provided ���� gpd Plan: Date /= /% // % Number of sheets a Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS .� ^6]�&,� ti��/ [ 1 Cy 4 iia ► e c t%a n �Pa►[ C, The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 -and further agrees to of to place the system in operation until a Certificate of Co pli ce has been issued by the Board of Health.. Signed Date 031241JOIO, Inspections 7-2— o0..Dc"iC.:'...Z � ?FEE �`' 0 00MMONWEALTH OF MASSACHUSETTS ?0', Tc ,d Board of Health, MA. CERTIFICATE Of COMPLIANCE -�" r Description of Work: 0 Individual Component(s) -k Xomplete System The undersigned hereby certify that the Sewage Disposal System Constructed O, Repaired ( ), Upgraded ( ),Abandoned ( )' by: t a„� C�fi �✓ .c °. has been installei accord_ ante with the rovisigns df 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No 1 r'd , dated - iv . Approved Design Flow .t'YO (gpd). Installer Designer: NM+d 4% e 51AInr °t� Inspector: Date: 4",,_' a The issuance of this permit shall not be construed d as a,gu tee that the system will function as designed. No. b o\ 0 c ~ ?c FEE -7 COMMONWEALTH OF MASSACHUSETTS cki 378 Board of Health,O J4 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herebygranted to;.'Construct( ) Repaih "$ pgrade( ) Abandon( ) an individual sewage disposal system at VC_ as described in the application for Disposal System Construction Permit No. 1© , dated Provided: Construction shall be completed within tiheai s of the date of this penis � lll local conditions must be met. Form `1255 Rev. 5/96 A.M. Su I 'n Co. Charlestown, MA Date!'� - Bo rd o Health