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HomeMy WebLinkAboutApp-Permit-ComplianceNo.. Ip�7�v'�� /� FEE' C®l 0NW1A111 Of MASSACHUSETTS c. ` Board of Health, �Mr] MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location , � �" Owner's Name 'em v� / (,Y-, _ Map/Parcel# 1(5 Address ll �s QGA\ Ltj : _ CSV' Lot# Telephone# Installer's Name '� Q �v P. C © Designer's Name P-1ve-_2v & IP �r� Address , -0 . 86X 3 Qt 9yO �y Address ,o . C6 ' 1 _ ",A► j� & Telephone# _L a+—� © Telephone# Type of Building Lot Size a , b & sq. ft. Dwelling - No. of Bedrooms Garbage grinder Other - Type of Building No. of persons Showers ( ), Cafeteria Other Fixtures Design Flow (min.'required) gpd Calculated design flow 33p Design flow provided gpd Plan: Date /�� Number of sheets Revision Date Title Description of Soil (s) OJAI R t-1 Z0,AJ & — LoAp N EA C- ko e' l Z o ,�J U• Ar ' Soil Evaluator Form No. Name of Soil Evaluator 64VIL L101 Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS -TNJ fQ1 I 1)"� 0 �,(121) 15® ® T z The undersigned agrees to ' tall the above described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to the in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date f Inspections • , Y \, s� Mew �.+°i�..ai.` W'? w A.. No, FEE G` COMMONWEALTH OF MASSACHUSETTS Board of Health, VagmokMA ,km. CERTIFICATE OF COMPLIANCE Description of Work: Q -Individual Component(s), ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded("Abandoned O` by: fz01-1r-1--T U 1 has been installed i�1 actor anc.e with the provisions of 31f1,CMR 15.00 (Title 5) and th approved, design plans/as-built plans relating to application No. IIV ' =� � � , dated � ` � ' /`Approved Design Flow (gd) ZZ -Installer t `� f'�y 4 ,r� dC �iC ". /I � Designer: gt&¢a fZl - �' e ) .� Inspector: w ,,f 60 46�/& _ Date: lo 12 The issuance of this permit shall n construed as a guarantee that the system will function as designed. l No. ��i 018 D I(�' F�,r'` �� oi-, E4`IT � , L e � tt C0 FEE COMMONWEALTH Of MASSACHUSETTS C� ��~12 Board ofHealtlt, DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at4�i?: �fi"- Po -r ::Mas described in the application for Disposal System Construction Permit No. , dd6ated / ) /if Provided: Construction shall be completed within v_W.M a� oft e date of this peri - it. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, M Date/ Board of Health