HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE46560
6 COMMONWEALTH OF MASSACHUSETTS
r- Board of Health, ia'rwt 00
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P14146 F® DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Allication fora Permit to Construct( I Repair( ) Upgrade(DQ Abandon( Complete System 0 Individual Components
Location 2, V Mq*q Ve 5 e 24
Owner's Name Arm c-.^ do 133ci r,-V� 1
Map/Parcel# 'Z� —Z%
Address 1� Luc' (Dt^, MiI�Mrd d 25-7
Lot#
Telephone#
Installer's Name � j /
Designer's Name r� ;rr,�
/�N�
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Address 3� h a1'' Z/(/ W tuG f )4%"
Address 1 Z Val G/fw4 _, tx j
Telephone# 0 - 31 CV
Telephone# QZ-4/71-5-317, �v C
Type of Building [ 7�q / Lot Size 1 6, 44N J-fsq. ft.
Dwelling - No. of Bedrooms Z i Id'urt Garbage grinder(
Other -Type of Building No. of persons Showers ( ) , Cafeteria
Other Fixtures AIM S 27::�
Design Flow (min, required) �� gpd Calculated design flow 3 a Design flow provided gpd
Plan: Date 1l�iT1 Number of sheets Z, Revision Date
Title l/`h0Q Ld SjSJL&" `-5:1-P I?LCL ZF Ma 40k 'C. 10_ Rld FlU i IYYt CJi1
Description of Soil (s) 0 10 n � 6a!ty Saotd I0-3 (; 40 If Ca-sn.4 SC� �'1 u � +
Soil Evaluator Form No. Name of.Soil Evaluator F4�"t Date of Evaluation ) O I lg I (:
j _t om
5+46[06— ,Adj 9'1?"'
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 the a til a Certificate of Compliance has been issued by the Board of Health.
Signed Date 7-2 3 -IF
Inspections
e ; -:C7 l� 'r,r� '.` �s� ' X,57 . Em's'.)
COMMONWEALTH OF MASSACHUSETTS 5
No. . � E� y'( i 1..• � `"'� FEE
r Board of Health, MA.
CERTIFICATE Of COMPLIANCE r�L � � w
Description of Work: ❑ Individual Component(s) AComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ); Upgraded , Abandoned ( }
at zmss' !I -R&I ' - %4d 41:
dated p"" A roved Des' n Flow �f p� d g p A ting to
has been installed in accordance with the provisions of 3 CMR 15 00 Title 5 and thea roved design Tans/as-built plans relating
application N�o.'-fit- ppg : a (gp
Installer ti ~I F r f
Designer:c: t i T : Ir t = u t` ',t r (i ;(J a Inspector: /4—,( � �. ` �; r �r Date:
The issuance of this permit shall not be construed as a guara4t6e that the system will function as designed.
No. 6 1 1 �� t G'-' 0 a � � � 1� L� tl 40 v ` FEE
-; COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y-9 e - ski tt HA:.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (j/) Abandon( ) an individual; sewage disposal system
at Ux.i telco i �� �.� =a''lA as described in. the application for
dated
Disposal System .Construction Permit No. d � � ..d
t C,
Provided: Construction shall be completed within -$re f t ie date of this permit. l,local conditions must be met.
!/ Form 12
f5,Y. Rev. 5/96: A.M.A.M."Sulkin Co. Chadeslown, A // Date , _ oard of Health , f ! - �' i, Z _-