HomeMy WebLinkAboutApp-Permit-ComplianceNo. otl 'L`I U'ZZ495 441"�uv /-1 I�l)�04Z Y' FEE'
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COMMONWEAITH Of MASSACHUSETTS clic
Board of Health, (7 ,MA. A
APPLICATION Y D O ryAL SYSTEM CONSTRUCTION PEN"I
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System Q Individual Components
Location
Owner's Name
?C)jjl At of P. 60(.4) �VK
Map/Parcel# ///z0z
Address /
0"d(?r d /If -1 / 1p -
Lot#
Telephone#
� � Y - 61v66 -
1v6Installer's
Installer's Name C f
Designer's Name
Address 6 ''!v� 1 li%J ; %�/
Address 2 -T 1/0 P. i,i� k, S /� (•(lir'
Telephone# O 'r QtZ _ 1 `/1�/�
Telephone#
-0
Type of Building Lot Size _sq. ft.
Dwelling - No. of Bedrooms Garbage grinder
Other -Type of Building No. of persons Showers( ),'Cafeteria,( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow -`7 'Design flow provided e d
Plan: Date Number of sheets Revision Date
Title
Description of Sbii(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS T -P % iC ' Lee�� %l /•�S 6 � l� � �/T e lje., S/ � l Ll -
The
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The undersigned agrees to install the above described Individual Sewage Disposal System m ccordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Complianas been issued by the Board of Health.
Signed Date 6
s
Inspections
No. FEE
C®MMON LT14 Of MASSACHUSETTS bicep %
Board of Health, MA. n
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 0 Complete System )>C7 /
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded/ Abandoned. ( )
has been installed '14-1 accordance with the provisio of '0 CMR 15.00 (Title 5) annda the ap ved design plans/as-built plans relating to
application No.,/ r , dated Approved Design F1ow and
Dd
Installer j2LL J f>'�� %1 7 ' % '1/Jlf1� ��l%Lolii'� -1 6'���'�G✓7F
- 1
Designer: !% v �}! �.' i t_ �:'� tai Inspector: 4z �r �{� Date:
The issuance of this permit; shall not be construed as a,guarantee that the system will function as designed.
No.--l�11� �(,`"�`�:-� °!> 1"�E'"���`��� FEE_
COMMONWEALTH Of MASSACHUSETTS CJ 0 P0-2-
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an inditridual;sewage disposal system
a `' / u' J ; 7 1, ,' / r, %': as described in. the application for
at / �L /'E' 1 � i ;
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within . o th&ate of this perpt. All local con, itions must be met..
Form 1255. Rev. 5196 A.M. Sulkin Co: ChadeSiOWn, MA Date�--�� Board of Health