HomeMy WebLinkAboutApp-Permit-ComplianceNo. tl t Ly 51,-S--
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COMMONWEALT14 Of MASSAC14USETTS
Board of Health, YCt IDM 4 1 J•-� MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade Abandon( - ❑ Complete System * Individual Components
Location �' �,r^ �( %��
Owner's Name Aa +-'Aa s1 �v�Z�vls t
Map/Parcel# �9 -
Address (o �y e+ /Zt( S g .-JAW
Lot#
Telephone#
Installer's Name//�
Designer's Name �n ; n-ee r.; n t4tjv(4) G
Address c� L[d �t Ck f!inii
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Address W, Cra>-'-4 (o(
Telephone#
Telephone#_ _ ' S 3 Q r—to 9Q
Type of Building ��3 aLe�• a%�-�t �a rtirJy Lot Size sq. ft.
Dwelling- No. of Bedrooms �� Garbage grinder ( )
Other - Type of Building No. of persons Showers O,'Cafeteria { )
Other Fixtures it (T .
Design Flow (min, required) `? 3 d gpd Calculated design flow Design flow provided 3 �� gpd
Plan: Date 13 ®1 (% Number of sheets ` Revision Date
Title
Desci
Soil Evaluator Form No.
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Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS Alt W f�
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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ Date
Inspections
No.�a FEE
COMMONWEALTH OF MASSACHUSETTS A LLL120
Board of Health, �/�"t �1% , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ✓Individual Component(s) ❑ Complete System
The underrsignecLherebycertify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned
by: t" U Q ek
at
has been installed in accordance with the pr vis 'ons of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. � �_, dated it Approved Design Flow 3T (gpd)
Installer �''} , - a e .- r . i
Designer: L, 1.1 C. twf`,t` 1)_WC" ✓ J Inspector: ti-•+= —1 lute;
The issuance of this permit shall not be construed as a, guarantee that the system will function as designed. f
No. h--62-41 FEE ),
1--7 —2240 Cf)M1 TWONIVrALTH OF MAXNACUT KIFTN +,t 3
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Board of Health, k - , MA.
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DISPOSAL SYSTEM CONSTRUCTION PERT41T
Permission is hereby granted to; Construct( .) Repair(, ) Upgrade( ) Abandon( ) an individual sewage disposal system
atas described in. the application for
Disposal System Construction Permit No. �✓' �-, dated c�
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M.;Sulkin Co. Chadeslown, MA Dateof Board of Health