HomeMy WebLinkAboutApp-Permit-ComplianceNo. FIoC^�b�f'1/"��%— / 7d2���j �' + FEE
C®MIMI®LTH ®F MASSACHUSETTS �'�'��/ 1e�
Board of Health, jtP= Ia Lr , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application foray it to Construct( ) Repair( m
pgrade( ) Abandon() - ❑ Complete SysteJsindividual Components
Location
/Vt w A
Owner's Name
b,
Map/Parcel#
`% ear
Address
HI „v Rd
Lot#
Telephone#
S"Or .? 9e- ?W_Z/VW
Installer's Name
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Designer's Name
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Address f/
Jv C av w -T
Aq/ 40-e`t- `
Address _
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Telephone#
D S --Q
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Telephone#
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Type of Building / e r
Dwelling - No. of Bedrooms
Other -Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Lot Size sq. ft.
Garbage grinder( )
INo. of persons Showers ( ), Cafeteria ( )
gpd Calculated design flow
Number of sheets
Design flow provided gpd
Revision Date
Soil Evaluator For No. Name of S it Ev ator Date of Evaluation
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DESCRIPTION OF REPAIRS OR ALTERATIONS e; o 14,,,e C d 1/, /) r i-aP ife sy dD
4/17-A -S adD 0_4 >/ _T e• A' 4-V 4 P 0UP ✓ Oat
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre!!t
P9,46t to pla e e syst in operation until a Certificate of mpli ce has been issued by the Board of Health.
SignedLl /
COM MON LTII Of MASSACHUSETTS
Board of Health,
CERTIFICATE Of COMPLIANCE
Description of Work: 2l dividual Component(,) ❑ Complete System
The undeerrsyig-ped hereby certify that the Sewage Disposal System; Constructed ( ),
at V -t & /c" 4 A a wAr A
has been installed 'n acc
application No.
Installer
U graded
�A
FEE S5, C
with the rovisic, of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated 'Approved Design Flow (gpd)
Designer: " '"""" Inspector:/,//`"'� t L'Gt( 04"4-1 Date: a
The issuance of this permit shall not be construed as a guatantee that the system will function as designed.
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No.
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, YYA9MQ , MA.
➢FISP®SAI. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair4,,* 'Upgrade( ) Abandon( ) an individual sewage disposal system
at117- 1/=+? /-// r is /S B & 1r P as described in the application for
1
Disposal System Construction Permit No. 11C ;-dated
Provided: Construction shall be completed within tktt>tieg„yef the date of this permi . All local conditigns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date (n ` Board of Health J