HomeMy WebLinkAboutApp-Permit-ComplianceNo, Ok�C'�7— vFEE--,
/ APMMONO LTII Of MASSACHUSETTS
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Board of Health, Yftaffl OlJ!l+ , MA.
AQP ICATION FOR. 1DISP®SA� TEM CONSTRUCTION PERMIT
t l fipplicatt on fora Permit to Construct( ) Repair( ) Upgrade( AbandonO - Complete System O Individual Components
Location J -s -al WSN kC{ v_t AA M01,{"f 41
Owner's Name o C
Map/Parcel#
Address �' j �.-1 IV I 15 LXAS, AAV rU-1,CH
Lot#
Telephone# -7 -14 -
.9-1 Q -3,3,5
3,5
Installer's Name i 1 �/� Qt/ �--�
Designer's Nam(�e. vl,i
Addres�a t O (d 'ix ISI . 61 4d
Address 0 Box 1
Telephone#
Telephone# . S -
(�
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS _
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees o not to pla enssyste in operation until a Certificate of Co pliance has been issued by the Board of Health.
Signed Date <)"
Inspections y✓ 1 G��J1 cG -U�� "
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COMM0 LTH OPMASSACHUSETTSC l " 2-7
Board of Health, - Q JT 9 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s); _U Complete System ,
The undersigned hereby certify that the Sewage Disposal System, Constructed ( ), Repaired ( ), Upgraded t4,. ,4andoned ( )
by:, I' ;"',�.ei- 111 1J C to It
at . I.,_
has been installed in acct ance with the
application No. , dated;
Installer 0 11_ A AL011 1� fil P U C1
ions of 310 CMR 15.00 (Title 5) and the pproved design plans/as-built plans relating to
/� . Approved Design Flowy�(gpd)
Designer: n Inspector: W Date: �
10f,The issuance of this permit sha not be constrded as a guar ' ee that the system will function as designed.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, —, �i� (�l�A' MA.
,
Ill[ �� L ��TSTEM tCONSTRUCTJON PERMIT
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Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No.17:�L dated Z "
as described in the application for
Provided: Construction shall be completed within three years of the date of this perm' All local condi 'ons must be met.
Form 1255 Rev.5 96 A.M. Sulkin po. destuwn,MA Date- �� Board of Health