HomeMy WebLinkAboutApp-Permit-ComplianceNo.��"4�� /(�/�✓/%t . ���%�r�i/ii FEE
6 COMMONWEALTH Of MASSACHUSETTS
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Board of Health, YPR1A0t�} ` Q-Ilo
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APPLICATI®N
FOR DISPOSAL SYSTEM[ CONSTRUCTION
PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad�Abandon( ) - 0 Complete System• Individual Components
Location
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Owner's Name
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Map/Parcel#
Address
77
vC wrr� On'
Lot# S''
Telephone#
Installer's Name
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Designer's Name
Address /G�w,-,r►�y
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Address as 3 -Sc l�w41, 's, Awls
Telephone#3G(,
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Telephone#
Type of Building /l /S VO►,A n 1 Lot SizeIr j ��� o � sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min.rU:2,0)
) '' gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �` �i�sr II �Gv� / �I—s g �_ �/��
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nAPC41 i f"�iAAS���c�� f�G/�►nc�� � .. Liac�y.
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 place the system in operation until a Certificate of Co plianc has been issued by the Board of Health.
Signed -- �l7 i-"7 — Date ��
Inspections
No. 1'4ibEi DC - ( (,Q 4 f U U 2-3 h � FEE 00
7/ COMMONWEALTH LTH ®F M ASSAC14USETTS 16
Board of Health, YA 12M h tl1'N , MA.
CERTIFICATE Of COMPLIANCE %& , � �o17
Description of Work: individual Components) C3Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded -e-), Abandoned ( )
by:
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has been insta e� a- ore-kce ivi ti?p4ovi,ions of 3110 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. Ab/ %/ dated 16. Approved Design Flow (gpd)%,,
Installer A - P- 1,4 - AT) !\ m 4-1 iCET5 .. ?n�rl0 /� - AV -or- � 1S hZ V,1
Designer: - 1-C — Inspector: / Date:
The issuance of this permit shall not be construed as a gua tee that the system will function as designed.
No. n14 o -1(0-( 00 Z-3 FEE
14-71 COMMONWEALTH OF MASSAC14USETTS
Board of Health, YP2M0VTU , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair< -) Upgrade( ) Abandon( ) an individual sewage disposal system
at L 6 t;, G A' o/4,1/P L as described in the application for
Disposal System Construction Permit No. K,dated -f-12
Provided: Construction shall be completed within th+@@-j ,f the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date4 r �L_ / >J Board of Health
v � ; .114