HomeMy WebLinkAboutApp-Permit-ComplianceNo.—/ / )����"�1 FEE
OMMONWEALTH Of MASSACHUSETTS
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Board of Health, >L- LN MO UTR "VM.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - Complete System ❑ Individual Components
Location QA L /Q (--i
Owner's Name FRANCO
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Map/Parcel# P_C ll� L
Address k UOTIAROVS
N LT
Lot# a3z
Telephone# W — to1
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Installer's Name ��,`,\ C�
Designer's Name
U -f 1 ��
Address -G . �
Address _3 "-1,&-
Telephone#
Telephone# S Q g —
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Type of Building leg irt,- W -T 1 A � Lot Size 56 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) c), gpd Calculated design flow Design flow provided _�l gpd
Plan: Date (i _44 1 Number of sheets Revision Date A
Title SE+P �l t• L �+� G T /�1 1�.
Description of Soil(s) lSAWDp
Soil Evaluator Form No. Name of Soil Evaluator�J �if A�� Date of Evaluation a O
DESCRIPTION OF REPAIRS OR ALTERATIONS R1V\A) 11 SOO GALLU n) P7 L Tip i S _ S3
A . W> m i t -k V I — A rN," X VTa e 111 K \,(— (-11=1 % v ..1 -,A- t7-1 V1 _K e l ,l .t' (' r'� .I C t';4 .A I
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of o pliance has been issued by the Board of Health.
Signed Date 2c�
Inspections
No.
COMMONWEALTH OF MASSACHUSETTS- rte
Board of Health,AV_MO I)M� , MA.
CERTIFICATE Of COMPLIANCE 10
FEE I"
Description of Work: ❑ Individual Component(s) )� Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired QQ, Upgraded ( ),Abandoned ( )
by: Nae '�A5T C 0 hl 5-(7e.
at 1.t "T-L).P� p LA C.1:
has been installed in ccordan� with the provisions of 310 CMR 15.00 -(Title 5) and he approved design plans/as-built plans relating to
application No. , dated —1-4 Approved Design Flo
(gpd)
Installer
Designer: Inspector: Date: V d
The issuance of this permit shad not be construed as a guarantee that the system will function as designed.
No.I O d x �'iT" �°'bNTI FEE 7 61
COMMONWEALTH OF MASSAC14USETTS
Board of Health, VA g -MO QT_AA , AVIA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(o Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 0 Tom:14\NO�_'ETo A 11 A C as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within th yea f the date of this DerAit. All local conditions must be met.
i
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date to (� ( Board of Health a 4
k.