HomeMy WebLinkAboutApp-Permit-ComplianceNo.,le 0010(006
so WD Cr(9 �� COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y MA.
1). /APPL1CATI®N FOP, DISPOSAL: SYSTEM CONSTRUCTION
Application fora Permit to Construct( ) Repair( ) Upgradefe�Abandoui( ❑ Completes
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MAY.?,11019
IividuaJ Compox}ents
LocationAA J i
Owner's Name
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Map/Parcel#
Address Gh
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Telephone# �,
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Installer's NameC� Q C T
Designer's' Name
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Address
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The issuance of this permit shall'"not
Address
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Telephone# — _
Telephone* —"2
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Type of Building Lot Size Soo sq. ft.
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers O, Cafeteria ( )
Other Fixtures
Design Flow (min. re uired) l l n gpd Calculated design flow9,10
Plan: Date 1t- Number of sheets
Title
Description
Soil Evaluator Form No.
OF REPAIRS OR ALTERATIONS
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Name of Soil
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Design flow provided —V7 -L-1 gpd
Revision Date
Date of Evaluation
`The undersigned agrees to install the above desc 'bed Individual Sewage Disposal System in accordance with theprovisions of TITLE 5 and
further agrees to not to place stem in o i until,a Certificate of Compliance has been issued by the Board of Health.
Signed Date .
.
Inspections 9Vx
No. 0 i t iP
COMMONWEALTHM
OF ASSACHUSETTS. 4 � o9L",56
Board of Health, p4md trr14 , MA. �, r
CERTIFICATE Of COMPLIANCE a �p .
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Description of Work: ❑ Individual Component(s) ❑ Complete System/%P �C JLf 6✓ ��
The undersigned hereby certify that thPoUr`)
Sewage Disposal System; Constructed ( ), Repaired (`, Upgraded ( Abandoned,{ )
by: } . ni 3
at PC--?
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has been installed in(accordance with therovisions 4-8I:0 CMR 15.00 (Title 5) an �e approved design plans/as-built plans relating to.
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application No.
! 9
dated %7 . Approved Design Flo -O (gpd)
Installer
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i 6 4 CG 447
Designer:1JC�ti
t-erp r i (Inspector: i �./� i Date:
'
The issuance of this permit shall'"not
be construe as a guava ee that thesystemwill function as designed.
No.i.)}''r'f;C�
FEE2.'sl
COMMONWEALTH OF MASSACHUSETTS
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.Board of Health, purr , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( °' Abandon( ) an individual sewage disposal system
at ; _J� c. B 1 d as described in the application for
Disposal System Construction Permit No, f ` ;J% dated --'
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Provided: Construction shall be completed wi.thin,tl�,re�� ks of t'lie. date of this permit. All local conditions must be met.
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Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date ? �� /Board of Health