HomeMy WebLinkAboutApp-Permit-Compliance13LpTA -1, -Gd0-5W
No. f FEE
C NW L Of MA Si
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Board of Health, _ ,/ &MO VTR , MA. `
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade�,<AbandonO - ❑ Complete System --d Individual Components
Location15
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Owner's Name 1,2 CJ
Map/Parcel#
5,0 3
Address
Lot#
Telephone#
Installer's Name ��
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Designer's Name P004- G�l v S'L W t1 t C
Address
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Address .�
Telephone#
S9& a612A 6
Telephone# QE
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Type of Building Lot Size l7t1� sq. ft.
Dwelling - No. of Bedrooms Vp Garbage grinder (5
Other - Type ofBuilding No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 C> gpd Calculated design flow Design flow provided 3-11713, �gpd
Plait: Date (yVN9 '3 Gl Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
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Name of Soil
DESCRIPTION OF REPAIRS OR ALTERATIONS ��'�/lJ s tea~✓ %r
Date of Evaluation 57– 31-1
The undersigned agrees to insto the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pla g tem a Certificate of Compliance has been issued by the Board of Health.
Signed o a ' Date '1
Inspections
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COMMONWEALTH OF MASSACHUSETTS
Board of Health,YAR-M_i l r , MA.
CERTIFICATE Of COMPLIANCE
Description of Work:LT Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
I,,,. r1 I "c iA r r,1 iv" t ("C & ( )-
at lZ) $b 4? 4S 01-,? K t j/ L Q jj4 -.3/ Uit 1 n YI* UL 111( 211 t E�� 4V 1f3.
has been installed in accorda ce with the provisi<ins of 310 CMR 15.00 (Title 5) and the ap r ved design plans/as-built plans relating to
application No. :- i< 4 dated e ��° 7 . Approved Design Flow d)
s
Installer i' , r 1 rt_
Y'14
�l' 1 Date: /
Designer: f Inspector: t
The issuance of this permit shall not be construed as a guaranee that the system will function as designed.
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No. l; C .' ( ! � ��/ LA S �,��.�.:..::� r FEE. `
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YN?– IM 0 t )Tq , MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT _.
Permission is hereby granted to; Construct( ) Repair( ) ` Upgrade( ) Abandon( ) an individual sewage disposal system
at i f 1,7 81212 42 `• A A C, Set/ rA M 12 M 421, -A -A s described in the application for
Disposal System Construction Permit No. > dated SF
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Provided: Construction shall be completed within.' bfthe date�lf this permit. All local co ditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ' L� �Y! (Board of Health
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