HomeMy WebLinkAboutApp-Permit-ComplianceNo. Ok��C_1�0—�1 EE u
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/, COMMONWEALT14 Of MASSAC14USETTS C903L14
Board of Health, )6W= 0T q , MA. 7- OOJ, 73
Wip APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Ap lication for a Permit to Construct( ) Repair.\} Upgrade( ) Abandon O - ❑ Complete System ❑ Individual Components 57 g
L cation 1) _ Owner's Name Q Gt^
Type of Building Bess°Ch AA ) Lot Size et SS sq. £t.
Dwelling - No. of Bedrooms FGA /" Garbage grinder( }
Other Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) LINO gpd Calculated design flow 1.'7Design flow provided pd
Plan: Date iU Aa L /noi cd Number of sheets Revision Date —: I
Title
Description of Soils) CJ Mtd/u^a S,enGiI
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �+� II -LLxez -9a) e, An C 1x,... i)r/� . Nth/
'�1.S�Id,Jhd,� %1nX
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 system in operation until a Certificateof o pliance has been issued by the Board of Health.
Signed Date 114A jaol
Inspections
-I(Z0- 1-e /iyD ✓WDQV 4
v
No. 1(O-'-7 Za K /� FEE
CO�1[MONW ALTH OF MASSAC T
Board of Health, vwqemagN , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 41ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (-r,'jbandoned ( )
by: CC. 54 '%r,-,
at A Pt7 J d P
has been installed in accordance with they
rovisions of /310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated -,oZ -/�. Approved Design Flow (gpd)
Installer .0
Designer: _ SC D Inspector: x'64 C (4W ,f0%„ Date: f t' r/V
The issuance of this permit shall not be construed as a guar*4tee that the system will function as designed.
No. `" (0""1-72-0 k .fCv-LAti FEE 55. <J�
-77 COMMONWEALTIJ Of MASSACHUSETTS
Board (?f Health, "'V _ -M 0 -- MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair's} pgrade ( ) Abandon( ) an individual sewage disposal system
at Gpfj� 264 A as described in the application for
Disposal System Construction Permit No , dated -�
Provided: Construction shall be completed within ��of the date of this permit. All local conditions must be met.
Form 1255 Rev.. 5196 A.M. Sulkin Co. Chadeslaxn, to Date 6 Board of Health -__ t _
Map/Parcel#
'53
Address 0S
C Lx K CLW e4
Lot#
Telephone# -179 -G 3/, . L' 90'
Installer's Name R.., L4. CG�� ���/W
Designer's Name 13 5
Address
G BU�r"71ri �G►r o 17r� �a(,G`/
Address fit%
,j�
tS� �/l�'�hlv,✓�', rJA
Telephone#
G£, _ -fix - G `/L D
Telephone# 50
b. 77 _ Cl
Type of Building Bess°Ch AA ) Lot Size et SS sq. £t.
Dwelling - No. of Bedrooms FGA /" Garbage grinder( }
Other Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) LINO gpd Calculated design flow 1.'7Design flow provided pd
Plan: Date iU Aa L /noi cd Number of sheets Revision Date —: I
Title
Description of Soils) CJ Mtd/u^a S,enGiI
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �+� II -LLxez -9a) e, An C 1x,... i)r/� . Nth/
'�1.S�Id,Jhd,� %1nX
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 system in operation until a Certificateof o pliance has been issued by the Board of Health.
Signed Date 114A jaol
Inspections
-I(Z0- 1-e /iyD ✓WDQV 4
v
No. 1(O-'-7 Za K /� FEE
CO�1[MONW ALTH OF MASSAC T
Board of Health, vwqemagN , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 41ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (-r,'jbandoned ( )
by: CC. 54 '%r,-,
at A Pt7 J d P
has been installed in accordance with they
rovisions of /310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated -,oZ -/�. Approved Design Flow (gpd)
Installer .0
Designer: _ SC D Inspector: x'64 C (4W ,f0%„ Date: f t' r/V
The issuance of this permit shall not be construed as a guar*4tee that the system will function as designed.
No. `" (0""1-72-0 k .fCv-LAti FEE 55. <J�
-77 COMMONWEALTIJ Of MASSACHUSETTS
Board (?f Health, "'V _ -M 0 -- MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair's} pgrade ( ) Abandon( ) an individual sewage disposal system
at Gpfj� 264 A as described in the application for
Disposal System Construction Permit No , dated -�
Provided: Construction shall be completed within ��of the date of this permit. All local conditions must be met.
Form 1255 Rev.. 5196 A.M. Sulkin Co. Chadeslaxn, to Date 6 Board of Health -__ t _