HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0CLl FEE�ov
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, l CIL 't''"" 0 `' �� , MA.
7t 6_&q , 4VAPP �CATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
1pphcau�or a Permit to Construct(,X Repair( Upgrade( Abandon( - ;Complete System ❑Individual Components
Location
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Owner's Name TZ -41s,11 4 S; Cit.- -0
Map/Parcel#
kA q — 0 OZ
Address z'4 (t k C_
Lot#
Telephone;
Installer's Name
15tte-" k SAV114 U -L.
Designer's Name .— GobnA d ,K
Address -&v?
Qve_e,` Aviv-_ W c.
Address
S I Qv CN'ed�.41,
r
Telephone# 157M9 (A31 '9 if 1 TZLe
Telephone# �-�j%--11 7(og �'1 j t) -Zt0 1j 1
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
.:7
jrZ
iA
No. of persons
Lot Size l 0 I to 0C) sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided
gpd
Plan: Date Number of sheets Revision Date
Title V p� k.CtL,, U G4 1�nJ 1VJ C►iMtn C-� 1''{�
Description of Soil(s) jTIP'QZ (v U Z L S
Soil Evaluator Form No. _ _ Name of Soil Evaluator I ��MC Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 60Mr c'�k P
undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
er agrees not to/ulace the system in operation until a CVa
of ompliance has been issued by the Board of Health.
Signed /Z- 1 1
InspectionsAlcliTId
No. g g ',- 3�J
&�
COMMONWEALTH LTH ®F MASSACHUSETTS' 7�
Board of Health, Y6 + AIt UV k., j � , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) *omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.(, bandoned ( )
E. -
at '! 5 kAA Cl. , Mme. 9.I
has been installed inQcor a ce with the provisio s,of 310 CMR 15.00 (Title,5.) and the a proved design plans/as-built plans relating to
application No. + S I t dated a E i t l4" Approved Design Flow �-' (gpd)
Installer Zai!P.'/ K4F t.':..
,..;.,._ .,✓ Date:
.,� ,
.,'
�stgnel. 3nspc
--- The issuance of this permit shah not lie cons'tr`ued as a guararitll� that the system will function as designed.
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No. 1'� C. "' G ���l �� -^� Le FEE
COMMONWEALTH LTH OF MASSACHUSETTS
Board of Health, , MA.�
F ;it fbJ
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(>) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at '_.� 1°u as described in the application for
Disposal System Construction Permit No. �`�'' , dated c)- /
Provided: Construction shall be completed within. r.Q*e_wrc&-tlxe d tq_of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date � f 7 /L Board of Health
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