HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6J) --VZ— V) " OO 0 IS
FEE 466"00
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WIVEVIVAwtALIff Oi NIASSlk-ff u 3h l TS
= Board of Health, Y&} o y -n4 , MA. k6t� ei- I -e -e-,
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade.(�bandon( ) - ❑ Complete System"'l7Individual Components
Location 3qK
Or
Owner's Name
Q M d NC)
M Q N S
Map/Parcel# 3
Address
rj(j (1 Ln
Lot# a 1
Telephone#
Installer's Name R 06,e s-` j
g )U r
c < Designer's Name
�� (j{L
egr�y
Address o : 1 3
1,xi�,
H�
q , Address , d :
7 1,10-S1/��
Telephone# -- 40a -o
6 0
Telephone#
L
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date ('01 6 ? Number of sheets
No. of persons
Lot Size 06:1 sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Title
Description of Soils) R l e>> k6 rIZON S'" L.O A N►`1l '58 C_ - R6 T-)-ZPr' " Mp-GPd SA
Soil Evaluator Form No. Name of Soil Evaluator A N,j �bA- , Date of Evaluation 7 ,
DESCRIPTION OF REPAIRS OR ALTERATIONS
QN 1a)n
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 a the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �0 Date (oI &®l )-)
Inspections
No. G`✓ i ?G-1-2rl FEE ��a • �i�
1-7_ �, �` COMMONWEALTH Of MASSACHUSETTS
of ���,,�`'�' �. 00a 175
Board of Health, 'YARM 00-N , MA.
CERTIFICATE OF COMPLIANCE ul i
Description of Work: Individual Component(s) ❑Complete System.
The undersigned hereby 4.
by certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded„-� Abandoned
1w O
by: �fl � 00 1Z C Ci l^•%
at ��r
has been installed'n accord ce with the provisions of 310 CMR 15.00 (Title 5) an�r'�he-a proved design plans/as-built plans relating to
application No. `.� /�~!� % dated -7 1�4 �% Approved Design Flow " _ (gpd)
Installer (-. s- S D a JCC -
Desi
Designer: �`ai\ e� tU�'�t:.y- 1ENC�1A-.), r !' � � ? !� r
g Inspector: Date:
The issuance of this permit shall not be construed as a guaran eat the system will function as designed.
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No.
� �� � ' � �i _. i.� t,(c-:;p 0 OV, FEE w7 t
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, YA Wrn O UTI� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (C,�bandon( ) an individual sewage disposal system
at �'S� j !'� , _)G !) �: b c�� )Y, as described in the application for
Disposal System Construction Permit No. �� i !� , dated
Provided: Construction shall be completed within of the date of this pernpi ,,All local co d' 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, Mn Date oard of Health .. � � _ -