HomeMy WebLinkAboutApp-Permit-ComplianceNo. _/G� FEE _
17` C®MLMO 1 I.TII ®f MASSACIIUSETTS
Board of Health, O , MA.
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APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon() AComplete System ❑ Individual Components
Location W
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Owner's Name C 5 V
Map/Parcel#
Address
Lot#
Telephone#
Installer's NameDesi
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Designer's Name �J cr1�j
Address
Address o �?
Telephone#
S
Telephone# S4 % — f
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
/.--4 1
Lot Size /1 ; sq. ft.
Garbage grinder/VO
11
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) �9 O gpd Calculated design flow 35� Design flow provided 3 -5%5" gpd
Plan: Date �'f �`—"'` t NN ber of sheets Revision Date
- - . _ , .-,- .4 _
tle
Description of Soil(s) _
Soil Evaluator Form No.
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Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS ��� o
C -279(d/' $ate ofEvaluation V—,
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3 He—
The undersigned agre ;itall the above ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o pltheteo n until a Certificate of Complia has been issued by the Board of Health.
Signed Date
Inspections W- '( >-
N o
No. FEE' [� V
COMMONWEALTH LTR ®E MASSACHUSETTS
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Board of Health, � dt'� A , meq. CC
CERTIFICATE OF COMPLIANCE pVi
Description of Work: ❑ Individual Component(s) gVComplete System
The undersign hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded), Abandoned ( )
by:
at
has been installed i accordance with the provisions of 310 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ��, dated — Approved Design Flow :3 4;i;—(gPd)
Installer !GL
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee tha the system will function as designed.
No.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YA k -N O O nj , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
FEE�G�
Permission is hereby granted to; Construct( ) Repairr((,� ) Upgraded) Abandon( ) an individual sewage disposal system
at - _' e 5 f �' '� `'y as described in the application for
Disposal System Construction Permit No. d %- Z Sz/
Provided: Construction shall be completed within tl�s oi the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.�M.SSulkin Co. Charlestown, MA
,%� Date Board of Health / D