HomeMy WebLinkAboutApp-Permit-ComplianceNo. O C --1-7-V 79 FEE 4a,60
7� C MM ONW LTH Of MASS CHUSETTS
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Board of Health, T1a'i��1 o lit) '
ICATI FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair( ) Upgrade (6< -Abandon - [fd'Complete System ❑ Individual Components
Location
Owner's Name p V
Map/Parcel# z
Address c QY YA
Lot#
Telephone# ZzD
Installer's Name
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Designer's Name
Address Vd
Telephone#`��
�5 �'
Telephone#
Type of Building s o Lot Size r7? `r'C-.), sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) 33 6 gpd Calculated design flow Design flow provided 336 gpd
PIan: Date \Z? 1��� Number of sheets Revision Date
Title
Description of Soil (s) 'V G n
Soil Evaluator Form No. Name of Soil Evaluatorb d\I\e--g,e5—f-f Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ��-�5 �a V n 1 /�� % S D 0 s�i�d k �t s
Q, -t -A n C(M.-w.f1--9t- 11� ?�.�c .... nom! l-. 1'c -,e-.')--- ra� Cr zz"Z
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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 sys em in operation until a Certificate of Co7-3
ance has been issued by the Board of Health.
Signed /� i Date % 0 /,
IF
Inspections
No. Q C ' i 7P �1 f tel/ L%�� 7®'j���z-e:—��*�— ,. "F
EV
_.. C®MMONWEALT14 OF I' ASSACHUSETTS ® X535,
-' Board of Health,, MA,
CERTIFICATE Of COMPLIANCY
Description of Work: ❑ Individual Component(s) ad"Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (VT Abandoned ( )
by: !l��^�a �p Q ��
has been installed in accordance with the provisions of 310 CMR 15'.00 (Title 5) and thea Dyed design plans/as-built plans relating to
application No. �%A dated .Approded Design Flow (gpd)
Installer"
Designer: lN��e_ v r.. a,tc,"v',. Inspector:�/�,t�� Date: 1
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. i)U� � i u�r ii �� ._� � R-cFAU`i K_ct)vt;-e._` * ; �t �'S � v FEE
/7--0!;' COMMONWEALTH OF MASSACHUSETTS
Board (f Health, _ VA ()kMj: MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (C.,KAbandon ( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. ¢ :Z -0 C , dated �� 7
Provided: Construction shall be completed within t,kt.�e Y- of the date of this per i . All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslom, MA Date Board of Health
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