HomeMy WebLinkAboutApp-Permit-Compliance2W -C _zT — •'vl l/ K/'pC K o/ -5 4�Aeey)-? FEE /V (d ` eO
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Board of He11Z11t}6 ROUTE 28q
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O. YARMOU
APPLICATION FFOP,D��SAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 1_/{, L/ j
Owner's Name
/'i�q,•�- 2uc/l�j"�y _
Map/Parcel# y
Address
Lot# d-fI
Telephone#
Installer's Name - ��•q
Designer's Name h
Address Q �� K
Oa6 3 S Addres?3 I
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t/p `� FO r�. f GY
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Telephone# 7 7!l- J36- Qca/lo
Telephone#
v F - q-))- 5-3/3
Type of Building pwtl�f '15 Lbt.Size 30 X-3 ( sq. ft.
Dwelling - No. of Bedrooms 3j Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) .330gpd Calculated design flow 3-30 Design flow provided gpd
Plan: Date �� �0 2 Number of sheets 12 Revision Date
Title
Description of Soil(s) 7!7Ed .��9-�1 < h!'�► ���tGG l%O lJ"/'o(/ss�L�/Ci%' l�iyjl/�'�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS &Zfte�<-71C -D, /o P �c t
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur r agrees to not place the system in operation until a Certificate �of Compliance has been issued by the Board of Health.
Signe Date
Inspections
A%
No. U7 FEE
COMMONWEALTH OF MASSACHUSETTS P
Bgard:_of Health,yd¢� IV Cl& ' �-' MA
CERTIFI ATE OF COMPLIANCE
Description of Work: El Individual Component(s) CI Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (, Repaired ( ), Upgraded ( ), Abandoned ( )
by: O -W s co p . ..� w ZA-- �� &B C C 1 44�)7C �O �: r^ L
at /6 V yb, 2r, e, -,,s l'/mow r ///AM. 21 6 1
has been installed in accordance with the rovis'ons ofy310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow 5 3 U (gpd)
Installer `-i !� 5�7 J aC/ Z /f t ,C j1 •¢ �'T
Designer: 9dl Iiia Inspector: Dater D 2
the issuance
of this ermit shall not be construed as a guarantee , at the system will function as designed.
No. L l (/ /�'� " `iY j FEE 44e, U V
COMMONWEALTH OF MASSACHUSETTS
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Board of Health, � LNIG✓� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct()�Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 4I W f7 . o�q �1'we %� as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within t s -50f the date of thisrmit. All local condi 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date — V Aoard of Health