HomeMy WebLinkAboutApp-Permit-ComplianceNo. ��1C - C) -2 -43C) -2-43y3 y/� -
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COMMONWEALTH OF MASSACITUSETTS
Board of Health,
Y om- , MA. L.-trr-P,- (-7- 601 «a
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (vrUpgrade ( ) Abandon( ) - ❑ Complete SystemIndividual Components
Location '7,, -
r
Owner's Name C°
Map/Parcel#
Addressun=3� e 1, �--'�
Lot# a
Telephone# L q` Gl k . 6-2
Installer's Name
Designer's Name
AddressaJy
r \ B�
Address
Telephone#
. ca , ^ 6 d
Telephone#
Type of Building -� Lot Size sq. ft.
Dwelling - No. of Bedrooms `1 Garbage grinder( }
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 (D gpd Calculated design flow
Plan: Date Number of sheets 1
Title
Description of Soil(s) _
Design flow provided gpd
Revision Date
Soil Evaluator Form No. Name of Soil Evaluator C' \A`cso,r-',,,, Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -T� ✓� �C'�e 4� \e,- U_D W-_20 j7 t� ';'� �( �.►r,�-: �-i �'�a�
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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 syst m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed v —� Date I %
Inspections
J
No. Y C .. ®�.� �� �41FEE GV
COMMONWEALTH OF MASSACHUS ETT dr' � =r� * 2,8 Z-1
Board of Health, (Z.i1$ ® 4 TM , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: &ddiidal Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: i +
at "l/�r�,L1, .21y"X�r—,iA10) doe✓,�/
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has been installed in acc rd nc ith the p fovisions of�3 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. . ?� dated i° ^' / e Approved Design Flow,�.Lm (gpd)
Installer i Am-_" P4ma lQc-. l..i VA 0
/
Designer: ` uW (4- J f-• g (t 1(Y ( tQ . Inspector: Date:
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
No. 12�Qik10 C"lip-o"3 CZ Qy tc_oo le),L C_-xc FEE a.00
COMMONWEALTH OF MASSACHUSETTS ck-4 -2-6 Z-:7
Board (?f Health, Z JjM i, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(vr Upgrade( ) Abandon( ) an individual sewage disposal system
at �. ��ar'�--!.-� as described in the application for
Disposal System Construction Permit No. dated --a
Provided: Construction shall be completed within o the date of this per it. All local condition� must be met.
Form 1255' Rev, 5/96 A.M. Sulkin Co. Chadealown, MA Date I ' Q
pard of Health Lb"Z)U�
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