HomeMy WebLinkAboutApp-Permit-ComplianceNo. c-17-3363
17-62-- COMMONWEALTH Of MASSACHUSETTS ch4o"z-
Board of Health, MA. F L2 2 CQ
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PEI IT
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Application for Permit to Construct( ) Repair( ) Upgrades, Abandon( - ❑ Complete Systemndividual Components
Location
62�, Owner's Name
Map/Parcel#13�,
7 Address 7 {
PeR-T
Lot# `
1,q AfZj2r1 MtQ(tjpTelephone#
Installer's Name
iv Designer's Name/VD R4
F,
Address
,G' Address
T
VACrl IM
Telephone# '`-
Telephone
Type of Building ���c Lot Size sq. ft.
Dwelling No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers( }, Cafeteria ( )
Other Fixtures
Design Flow gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date /V
Title
Description of Soil (s)�'
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -�
The undersigned agrees to install the described Indi ' ual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree t to place in operation un ' a Certificate o li been issued by the Board of Health.
Signed i Date
Inspections
No. 1) C -1 %-33- 3
Description of Work ndivid
The undersi*F&A hereby certify t
by: In
at
has been installed in accorda
application No,,--/
'
Installer
COMMONWEALTH OF MASSACHUSETTS
Beard of Health, �,>IOvM , MA.
—CERTIFICATE Of COMPLIANCE �
Component(s) omplete System
ewage Dis osal System; ConstructedRepaired( Repaired),Upgraded andoned ( )
WA 99 00 1 tZ A til
with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
"dated —sS7 -d /7Approved Design Flow�"�^�i (gpd)
Designer: "r -14 -reek-ri zjlow Inspector: jfi`L_? V " " Date:
The issuance of this permit shall not b construed as a guarantee that the system will function as designed.
No.C 4''r "3: % r FEE 55-
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7- COMMONWEALTH OF MASSACHUSETTS Ck-W (o-72,
Board of Health, V,&e Y QUT 4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hers eby rannted io; Cons ruct( Repair( ) Upgrade,O Abandon( ) an individual sewage disposal system
at N �e}LCW , ,i_T as described in the application for
Disposal System Construction Permit No. d ✓!�'" lh 2 -;-dated
Provided: Construction shall be completed withiil,-th;�L�f the date of this permit 1 local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date /r Board of Health ,
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