HomeMy WebLinkAboutApp-Permit-Compliance`No. �Qv� t/C'"l�Osf?�S i-�'✓l.� /- h V L �p FEE $66 -,Vo
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Board ofHealth,tT , MA.
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��L TION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Constructk Repair( ) Upgrade( ) Abandon( ❑ Complete System O Individual Components
Location t� 2-- h16 dv
Jq%(, Owner's Name �/4 �
Map/Parcel#
Addre.. 2 51PI/4✓V A' IS,&dk ko
Lot# Z 3
Ga " 2
Telephone# -5-d,63 d �- . JM5
Installer's Name ! �. /� C
Designer's Name 377i?-r:50tV �QLL
Address /8'Z et V/X
Address
Telephone# 0 - �j
Telephone#
Type of Building WE% L�ily�
Dwelling - No, of Bedrooms
Other -Type of Building
Other Fixtures
Lot Size //1 sq. ft.
Garbage grinder"
No. of persons 2 Showers ( ), Cafeteria ( )
Design Flow (min. required) Jy gpd Calculated design flow Design flow provided '441'9" gpd
Plan: Date 'rZ 6 .�- 9q Number of sheets Revision Date
Title
Description of Soils) M ?Q 4AGft
Soil Evaluator Form No. Name of Soil Evaluator Date of kaluation
ug-- �,F, e,r�'si��y'�✓_
DESCRIPTION OF REPAIRS OR ALTERATIONS Ii yvld (/ z, -,S-00 6-,4&oh1 )-eA(i. �-1,,f
C44 fog T�1rr-�"P cJ�" CdJJirYi�T� rr�? S',t� tS Til t. � U / .�1�1�/I P - �1�17 � �'.C%��b
.; - 50Z1 �AQ/-iine�31 C� p4w S 0y-11Vf �r �� ' y 11,e3 "X Z'
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr�ee� notft to place the
system in operation until a Certificate of Corn liance has been issued by the Board of Health.
Signed Date 4
Inspections
No. [AD -c 3Lt" } i FEE ti)
COMMONWEALTH OF. MASSACHUSETTS k
Board of Health, G2JMha Rid " , MA:
CERTIFICATE Of !COM[PL NCE .
Description of Work: El Individual Component(s) ❑^`Complete }Sys tem = ..
The undersigned hereby certify that the Sewage Disposal System; Cons`tru'cted 'epaired ( ),,,Llpgraded O,"Abandoned ( }
by: h., Y icy—T' !�st'tC ,E712Yt
at 200 K P40 -L)Ayd MO 9
e .» ' � '" z
has been install r ce rt t e rovisions of 310`C 1- '00 (Title 5) and e proved design plans/a"s-built plans relating to
application No. dated Approved Design Flow (gpd ;
Installer e i l
Designer: Inspector: Is A" Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE
SE
COMMONWEALTH OF MASSACHU 'T TIS (,o&/
Board of Health,f �yf ('t A , MA.
DISPOSAL SYSTEM (CONSTRUCTION PERMIT
Permission is hereby grantedp; Construct Repair( ) U grade( ) Abandon,( ) an individual sewage disposal system
at %/af✓ IY' e,Y1/t i? u l,-�' 1
& � as described in the application for
�Dtspol--Sy��fiem Construction Permit No. ,dated �? /-?—/
T -L
Provided5 Construction shall be complete within three yearn of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadetown, MA Date '" i `7-6 Boar of Health zcllil
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