HomeMy WebLinkAboutApp-Permit-Compliance/MLt �—Ae _ 1 FEE
. / Z COMMONWEALTH Of MASSACHUSETTS
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Board of Health, ` LA,@: '10%yM , MA.
APPLICATION L'®I, DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Constrct Repa' () gra e ) ando - 916omplete System ❑ Individual Components
Location
Owner's Name T�'1 �, ( jMa %Veld e5
Map/Parcel#
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Address
Lot# r
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Telephone# 5-()9 d5- -• 83 Got- 03g
Installer's NameUn
i 4 -5 Cp/jSViL Designer's Name 6#vze- rim
Address
VIOLA
Address
Telephone#
; S _a
S '; Sb(�_ Telephone#
Type of Building C AR YM -4 X 0 C4 �M e(j{ Lot Size .-D . I'D sq. ft.
Dwelling - No. of Bedrooms - Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 20 gpd Calculated design flow A3 w Design flow provided .moi 3 t0 gpd
Plan: Date rJt 111:113 Number of sheets « Revision Date
Title cT-J j 0/?C)JOL4 —1
Description of Soil(s) 47i n J SUrl
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
D SCRIPTION OF REPAIRS OR ALTERATIONS an S H MW I (?.a\ "VT. r l�- $L Ik W&
The undersid to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree o;ees
to place the system in operation until a Certificate of . omp iance has been issued by the Board of Health.
Signed Date
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Inspections '�ydg
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No.tO`.' �t>c-1—i - lJO `5 7,
®� MASSACHUSETTS FEE
- COMMONWEALTH �e
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Board of Health pc ,MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) J2,Complete System
The undersigned hereby certify that Sew ' e Disposal System; Constructed ( epaired ( ), Upgraded ( ), Abandoned ( )
at L l2'x
has been installed in acc dance wit the rovis}fns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �� Z- datedr " �d� J AW17A441
ovFd Design Flow,�� gpdWor.
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Installer y"G r. �� Ifl-f %a/�il1 {
Designer:-''�� Ok L-!� w�01 Inspector: ( X of `K � Date:
The issuance of this permit shall not be construed as a guara>fre a that the system will function as designed.
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Z COMMONWEALTH OF MASSACHUSETTS _
Board of Health, Ajzt&U Q -D4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( 'j Repair( ) Upgrade( ) Abandon( ) an mdividu 1 se a e isposal system
at / � ( Ps �W(22 ;J1✓ r?/ r ,des z'�i' iz a application for
Disposal System Construction Permit No. /7— 4 2-, dated Z .
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Provided: Construction shall be completed within +re Tears of the date of this permit. _ 1 local conditictas must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA gate % B9ard of Health /r