HomeMy WebLinkAboutApp-Permit-ComplianceNo.U—Ica'2Zq5 FEE
COMMONWEALTH Of MASSAC14USETTS
Board ofHealt/t
ARMOUTH HEALTH DEP .
, , .
1146
APPLICATION FOP, DISPW4WMM"4:M9RUCTION PERMIT
Application for a Permit to Construct(gl Repair( ) Upgrade( ) Abandon( ) -%I - mplete System ❑ Individual Components
Location (D' EA
4 Viet' bP,"U Ln
Owner's Name
Map/Parcel# (
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Address(DI
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Ln
Lot# UV
2&jt' 77f—),C(—
Telephone#
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Installer's Name r
IInc.
Designer's Name Mum
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1 L
Address 0
I L I I a. -MLI
Address
2 Q
Telephone#
Telephone# 08
— 4 .. V371 D
Type of Building ze- i Lot Size �sq•
ft.
Dwelling - No. of Bedrooms eZ Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow d Design flow provided � d
Plan: Date Number of sheets Revision Date
Title 1-1 ar)L 4!
Description of Soil(,)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 11 •rQ _ IBJ in n
The undersigned s to tall aliov e d Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not pl e e tem ' op r �KTTuntil a Certificate of Co �lianc has been issued by the Board of Health.
Signed Date
Inspections
USETTS
Board of Health, a � `. MA. , s
CERTIFICATE OF COMIPM ANCE - -
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby ce'rtify,that the Sewage Dispo`satem; ConstUAbandoned(
b l c�t +--2_s r� IN) e
Y 6 � C�
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has been installed i c�or e with thepro "'°ns o 10 CMR 15.00 (Ti e 5) and the ap r veM design plans/as-built plans relating to
apphcatlon`No.,� dated Approved D�s�ix;low i pd),10,
Installer --7AFN
Designer: f4a4t3 4�-ly 6 1 f,)k64Z4 �Zr'"'Inspector: '� (" Dater
ay`t .
The issu4nce•of this per shall not be construed as.a guarantdlthti eem will function as designed.
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No.
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Board eatth 9' M cdb+� MA.
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Permission is here0grAte,.dto, Gor r, �p U grade Abandon( rtdivtd lsewage disposaT'systerry
at, �' L' �� �" r N a ✓ S °'°Wt�g�ygY� �s
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a • Ki lop �"� t i fi ,�� .' ', �' N N � �v
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Provi<ec� 0 1 blebm�ie ° thin ree year' - kltiar r l All local con ons must be met
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125,5 Rev 5/96 'A S std o Boston MA Board Q
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