HomeMy WebLinkAboutApp-Permit-ComplianceNo. o DC 6—lll t Z,,
f 6 f 7?, COMMONWEALTH OF MASSACHUSETTS 6 Loi -)2
Board of Health, Ya=Q l , MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION ,PER IIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon() - - omplete System ❑ Individual Components
Location
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Owner's Name ryrl— jeLj SY/y
Map/Parcel#
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Address
Lot#
Telephone# S O % 3 C
Installer's Name
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Designer's Name P SGV) kk`'---
Address,-
Address j9p (/j—it3
Telephone#
application No. !° dated
Installer ! (4 �j t lit �'C''t % Qf/C.p Yl
Telephone# %� Oa Q i -j 8�3-2jr
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Lot Size A®�
Garbage grinder (�
o. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) -401�v gpd Calculated design flow Design flow provided /K -c pd
Plan: Date 6" A�Number of sheets -� Revision Date 4 — �1-,1 �'
Title _ A/� Com[/ ) z3 a Ytal i /, / 4 /' S-7 CW00-4*
Description of Soil(s) ��� GT6 V
Soil Evaluator Form No. Name of Soil Evaluator ��%� G'�Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S� �� Vt -Y/n
The undersigned es to install the above describe Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees of to 1 the to ' o n a Certificate of
Compliance has bee issued by the Board of Health.
Signed Date C� "' "'`
Inspections
No. t r t+ 1J�-- t �" i f �..
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COMMONWFALT14 OF MASSAC14USETTS
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Board of Health, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 4PIro-inplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.F-�j'"t�bandoned O
has been installed in accord nce with the roes ons of 10 CMR.1�5.00 (Title 5) and the appro design plans/as-built plans relating to
?; Z' &' %tee. Approved Design FloI�,' d)
application No. !° dated
Installer ! (4 �j t lit �'C''t % Qf/C.p Yl
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Designer: 0 Lt f) S /v'► � Inspector: Date:
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The issuance of ,this permit shall not be construed as a guaran a that the tem will function as designed.
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No. i (� E k� _ 16 FEE
- �--- COMMONWEALT14 OF MASSACHUSETTS � ` 9 -2
der Board of Health, Yl -} , MA.
➢ISP®SAI. SYSTLM CONSTRUCTION PERMIT
Permission is herebygranted to; Constrttct( ) Repair( ) Upgrade
�Abandon( ) an individual sewage disposal system
at� ;�tt. �s 9.v� �'�` �• _.�-~ t"P' _-__ _ as described in the application for
System Construction Permit No. /� r l- , dated -7-
Disposal 0.
Provided: Construction shall be* completed within tfiFRe-fejrmf t date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown. MA Date? Board of Health
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