HomeMy WebLinkAboutApp-Permit-ComplianceNo. 00G13 4
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Board of Health, �Y,._ O t�� � , MA.
��-,`-„'fKPLICATION
�,� FOR DISPOSAL SYSTEM CONSTRUCTIOMP I MG
Application far a Permit to Construct( ) Repair( ) Upgrad Abandon( - O Complete System 2rTn-dividual Components
Location �.. �t/ �h cS
46 's Name
Map/Parcel# °a 1
Address y E-,)1,VY rt$ % 04-
Lot#
Telephone#
Installer's Name �y I' �S v, (01k 6 CO yl
Designer's Name )Q L,1 n JL %�%!
Address 3 h t
Address 4 S,
Telephone# S pi- 3 &d
Telephone# S cl S Ce -1 371
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Lot Size
sq. ft.
_ Garbage grinder { )
Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)/ gpd Calculated design flow Design flow provided gpd
Plait: Date` 12 j d-0) umber of sheets Revision Date
Title
Description of'Soil(s) S -e -e S -0-, 'j I GS
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S P S &V U�VC Q P S 6,
The undersign/agre' tthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees at a syylem ' e n ur it Certificate of Compliance has been issued by the Board of Health.
Signed G Date J "��
/ WJoIFEE thl
CO MON�I:T14 Of MAS����IJ��
Board of Health,, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Q -Individual Components) e0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedbandoned ( }
.
by Nh.S PirovY;S c
at li �E �SiG�v �s�-1 Gt_✓1 �rtt j'Y1 Ic, F', •G�.l
has been installed in accordance with thisions of 310 CMR 15.00 (Title 5and the approved design plans/as-built plans relating to
application No. r dated Approved Design Flow (gpd)
Installer j _e,.j Cc $d -gi p
Designer: c.g rti EL l l it) (sf % ✓ C -?s Inspector: Date:
The issuance of this permit shall not be construed as a guar �-,iat the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS �
Board of Health, __, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissrott`g is he5.-eby granted to; Construct(
at ,-A Yf ;? i,/ s)—\ CT rt;(- \
Repair( ) Upgrade {,.�-<bandon( ) an individual sewage, disposal system
as. described in the application for
v f �
,Disposal System Construction Permit No. /� , dated ��
Provided: Construction shall be completed within tl}r.e1§e? date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadegown, MA Date L / 7 Board of Health
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