HomeMy WebLinkAboutApp-Permit-ComplianceNo. �rTDC" ��""�71� �1y�..��''���f� FEE'ic}�
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Board of Health, 1 i�rS' , MA.
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APPLICATION FOR DISPOSAL SYSTEM CO TRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(/�bandon() - Complete System ❑ Individual Components
Location
Owner's NameC—L ck AKS&4 -Mie. �=(E
Map/Parcel# 7.9 la3q
Address 11 WARVESZ D (sytcA Pbla
Lot#
Telephone#
Installer'sName R LLC
Designer's Name `�1L ��� XW—
Address 55T mAsopE�G-
Address a$S+ CAkJ G
Telephone# _ —
Telephone# 5 nT< — oZ 7
Type of Building R t= r? co N'l' Lot Size 13# 4t/D t 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 .355.. % gpd
Plan: Date Number of sheets Revision Date
Title :5Tt LES 1ZnAo YAR AOLJJ (
wt�tQM s Ua 59L .3."'r
Description of Soil(s) �}
Soil Evaluator Form No. Name of Soil Evaluator R •T i PA 81sf k► Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS TAJ 5`t'tl•LL- NEW I, J 0 O G014 -L�
NEtQ D-Rok Ta aO i4A<1134 e -M&A -EPS lIBJ A FIC—L1b C�ll.9�tE��4Tl�N
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t o to place the in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections / U 4L I 7y �C d, A) S� �S To",
/Z t Se rz l7 � �3G?G
No. FE
Board of Health, d t rT! f , MA.�rf �b
CERTIFI rE OF COMPLIANCE
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Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Aban�done ( )
-44 by. t,.C-t�3tLic_n1'C�RJS t.L..C,_,
at at Sr/e--7s RO.tip Y &.;,r
has been installed �n acc r ance with the prop' tons f 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. A6 —.2c , dated 7 Approved Design Flow -3�(gpd)
-��oW —/7,Installer <.P�wtD� _ a.t�wp tA-PFZ
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Designer: 'IT -C Inspector: ( k�& Date:
The issuance of this permit shall. not be construed as a guar ate that the system will function as designed.
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No. iO�C -� iCi^li FEE. ®®
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COMMONWEALTH Of MASSACHUSETTS CA. 3
Board of Health, YIi 2M01. T1+ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade,(."rAbandon( ) an individual sewage disposal system
at/ �- `ate �ie�� as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completedwithin t of/t�h`e.�de of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health_(
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