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HomeMy WebLinkAboutApp-Permit-Compliance(� _/x/Ifo F No. tJ� � 1 � ,�(i ' 0 f5 0 3 FEE' ®1T �� ASSAC1�TT� ERETE V f.'�-off od / S`C) , i 6�,Board o Health, MA. U .�'� f �? 2019 3 %' 6T LIGATION O DISPOS L SYSTEM CONSTRUCTION iPEEALTH DEPT. Application for a Permit to .Construct( ) Repair( ) Upgrade( Abandon( ald Complete System O Individual Components Location Owner's Name r -V al Map/Parcel# '4 Address q L veil Lot# LlTelephone#S So , L Y Installer's Name RAW e- ©b, r- CbT j C Designer'sName ve> .0 Address ,0. -� & 5 y Address `ll.D'k O �L Q.Fn N - Telephone# � Tepho# s- Type of Building' Lot Size LSo 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 _ � Design flow provided G b gpd Plan:' Date " 1 Q ' Number of sheets _ Revision Date li 9 Title Description of Soil (s)'. d f Z C)Ki S" Cis A r C Ho r Z Soil Evaluator Form No. Name of Soil Evaluator PhIt14 Date of Evaluation S DESCRIPTION //Q.JO�F REPAIRS ". fls1 , , rtin,o 1 - -rLd C) CO -A -A TSE AO<t0 0 The undersigned agrees to ' the above described Individual Sewage.Disposal System.in accordance with the provisions. of TITLE 5 and, further agrees to not to a e syste , ' operation until a Certificate of Corpiiance has been issued by the Board of Health. It Signed Date C�/fill C Inspections. zJ 7 0,4� AJ No. 'IS FEE c / COMMONWEALTH 4ILTH OF IV S USETTS Board of Health,Zd�l®�7T' , MA. A _CERTIFICATE Of COMPLIANC Description -of Work: 0 Individual Component{s)'" �❑ Complete System The undersigned hereby certify that the Sewage Disposal Systers► Cdustructed ( ),.Repaired ( ), Upgraded Abandoned ( ). by: t b �' s 1 at €"7� R i /�l Q C` Lt' 4 has been installed in accord_ancci with the V.Pvisiqns of 0 CMR 15.00 (Title 5) and the approved' design plans/as-built plans relating to application No, " `^ dated " ! Approved Design Flow loa O (gpd Installer r -T, C C 4 r1j G Designer: 4e C- Qf-t_Inspector: ,6 Date: The "issuance of this permit shall not be construed as a guarantee that the system willfunction as designed. No. f OO AA DC 19 "-03 - 1 �..s FEE 9 `fit COMMONWEALTH Of. MASSACHUSETTS Board of Health, Ya:kw 0 ttiMA= "VM. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to;; Construct( ) Repair( ) Upgrade'(. Abandon( ) an individual sewage disposal system at_�"l� r'. �► J� as described in the application. for Disposal System Construction Permit No. fZ�4-/ ., dated !".e' Provided: Construction shall be completed withiti-th,��r_s`ofthe date of this permit., All local conditions must be met. Form 1255 ev. 5/96' A.M.Sulkin Co. Charlestown, Mn Date Board o£ Health o 1 0 //,i 4 .a I T! 7`- `u, , /C y J-"% bC° e .r, f"'i�r�i � �,�,w.� \ z9 -1-d