HomeMy WebLinkAboutApp-Permit-ComplianceNo. E,.A'4DC- I to'29DZ,3 P7 14,- ly G� �%/ FEE
COMMONWEALTH OF MASSAC14USETTS
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� A Board of Health, X111 f y ��' , MA.
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
lication for a Permit to Construct( ) Repail ) Upgrade( ) Abandon( -
LlComplete System ,lafln vidual Components
ocation
Owner's Name NC 4Z
Map/Parcel#j
Address 11,26t 3 Z
Lot#
Telephone# a y 7�f y �p
Installer's Na rne
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Designer's Name
Address
l
Q�S
Address
Telephone#
-50
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Telephone#
Type of Building �V J LC IC Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( }
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plait: Date
gpd Calculated design flow
Number of sheets
Design flow provided gpd
Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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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 lace th in oper tion until a Certificate of Compliance has been issued by the Board of Health.
Signed Date : 5 —V ( J
Inspections
No. �C r((o""$� �` (,\E�°
16 COMMONWEALT14 OF MASSAC USETTS
Board of Health, V ,e,Ouaji"i'!1 MA.
CERTIFICATE Of COMPLIANCEr,;C� A
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Description of Work: 'Individual Component(s) ❑ Complete System pg
The undersigned here y certify that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded ( ), Abandoned (
by: l•/ C1� C 4 Lof a v- / M 5 cy 40 or- //
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / - :� (�— , dated - 14 . Approved Design Flow `"" (gpd)
Installer 1 bl 7
Designer: Inspector: f .1 zov Date: i
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. RCkWCA —S'i2-3 kccU 54E* C4) - FEE It eO
- ;� �- COMMONWEALTH OF MASSACHUSETTS �44(053s
Board of Health, V&P M-01 }} , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair�Q( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at e 4N+ b �5, a Atjr 4 1-"C— YYY ��` as described in the application for
Disposal System Construction Permit No. %, dated 3 -7 / (a
Provided: Construction shall be completed within three years of the date of this permit A 11 local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadealown, MA Date �' 1.6 Board of Health