HomeMy WebLinkAboutApp-Permit-Compliance14V 00
2" COMMONWEALTH OF MASSACHUSETTS
Board of Health, st �/✓ 0 c MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair ('"r-U-"pgrade(-�Abandon( ) - ❑ Complete System l'Individual Components
Location
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Owner's NameV-W-rj•S c r t. t W-f-
Map/Parcel#y
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Address �7VK
Lot#
Telephone#
Installer's Name
ALS
W6 e U—C
Designer's Name Seo M�
Address
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Address ! o& 2P W
Telephone# f
5
Telephone# 6a g, L&Y- 3-73
Type of Building Flw.l
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
FE
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided 1?38 gpd
Plan: Date E� jc,ro /ft, Number of sheets "L' Revision Date
Title PA.
Description of Soils) 0—';c - amu^+ �i'' 3�Z `10A "'`7 3 z f �� f �
Soil Evaluator Form No.
Name of Soil Evaluator 7 TT 10 c 6AArA Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS I me. rAL L D—✓y)� A ^ick,_ nhrAA/ S A S l G.y J iPc
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees tp not to pl ce the stem in operation until a Certificate of Cox pliance has been issued by the Board of Health.
Signed Date Sr I I -i
Inspections
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FEE V 1 t
C®MMONWEALT14 OF MASSACHUSETTS
Board of Health, f f r'r v�,c� ✓ MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ly'Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( graded ,Abandoned( )
at `i ?- (X) (,<i i4,, -,r e t -
has been installed}' cco' d�ajn�je with the ro_visio4ns of3 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / rJ r/`' dated l/
//6. Approved Design Flow i (gpd)
Installer Y' t= `� l';' ✓ f tf ` ;.;
Designer. Cl C �f A Ai Inspector: _ i S Date:
The issuance of this permit shall not be construed as a guarantee that to system will funs on as designed.
No. ��t(�1�f /+l{ L 1I � '�"�� FEE 5 00
Board of Health, � � r � 0 v , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( —rUpgrade (") Abandon ( ) an individual sewage disposal system
at R. e C %1 ,- r, -�, " as described in the application for
Disposal System Construction Permit No/: ��� -; dated
Provided: Construction shall be completed within ttrr�s of the date of thispermit. All local cow itions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date A Board of Health ,`' `7✓� ''`/
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