HomeMy WebLinkAboutApp-Permit-ComplianceNo. �2C�'�
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biOA-EJOFM SACHUSETTS
Board of Health, )A& MO UJIN , MA.
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FEE .�S
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FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT
Application for a Permit to Construct(? ) Repair (V Upgrade Abandon( ) - ❑ Complete System Windividual Components
Location 11 D
Owner's Name
Map/Parcel# / 6 —. a��
Address
Lot#
Telephone# - 3
Installer's Name
Designer's Name
Address .7 _
Address , co . B %/ S v
Telephone# o .D
Telephone# S -C• 6
Type of Building 1Qo tdV�,j Ge Lot Size /'����t sq. ft.
Dwelling - No. of Bedrooms �U a o.o Garbage grinder MD
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) //0 gpd Calculated design flow ✓3 o Design flow provided 3S`f gpd
Plan: Date Z�; _. a 16 Number of sheets Revision Date
Title
Description of Soil(s) n -•-9 ' A � L 5` .0�" aG �[� Ls a 6 = /a'e t?o s�-,LJA
Soil Evaluator Form No. Name of Soil Evaluator ..y ! LCoA Date of Evaluation PZ .ir
DESCRIPTION OF REPAIRS OR ALTERATIONS (yyt STl,,9/ )4.) --,-A S" �_ I j C=44 i K� CW. ¢f a
/
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 toglace the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Zak .� . of L' .B9�ia9 Date
Inspections S' �`'' l l / f ' 7 ZL Lk41,7
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COMMONWEALT14 Of MASSACHUSETTS Qk
Board of Health,
b CERTIFICATE Of COMPLIANCE b 1�).o �
Description of Work: Q f dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (/), Upgraded (If, Abandoned ( )
by: 6 � C' %S
at /%^ ULA-ZAc'_ Lc 1f,rts! r *r
has been installed irrcco'rd5(1'ice'v$h the pi-6-69i`ons of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. "" (�� dated -V Approved Design Flow. -F-5-1 (gpd�1?9e-
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Installer ! ) rI Kt� � / •��'w's
Designer: _' l.ts i S �fii=,:�? t' :,t t'< ,it+z'nspector: Date:
The issuance of this permit shall not be construed as a gua " tee that the system will function as designed.
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No.
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FEES
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14-10 COMMONWEALTH Of MASSACHUSETTS CA --W 7-0 C>O
Board of Health, �d M OUT4 , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(-,/? Repair( ) Upgrade (V� Abandon( ) an individual sewage disposal system
at �tf n tie > _ , ICC- VoU u {n as described in the application for
Disposal System Construction Permit No./ !'� , dated
P elt hin t p
Provided: Construction shall be com lete wtthtn s o the date of this ermitr All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date i Boar of