HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSAC USETTS
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Board of Health, ��(- , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
.a A plication for a Permit to Construct( ) Repairt) Upgrade( ) Abandon( - ❑ Complete System U Individual Components
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.ocation r j 4e_ Zb CF*4p4-jbj Kf-Mj, Sra
Owner's Name I ' ° •
ap/Parcel# O �PD q
Address l jQ0 R-k 28 , C4,1.,"Tt,
Lot#
Telephone#S®7-.7`7/• 37 39
Installer's Name 4b&-T- &0VC C . -XAC,
Designer's Name
Address Zy 6rz�o+ oie s+e rr`• " . -M
Address
Telephone# 3' _ y Zo 6Sd
Telephone#
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 (mina required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �I1S� 1 ,/ W lI I'� OA J-_A O� 77t -TA'V1 t,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees, to of to place t/he_system in operation until a Certificate of Compli
ance has been issued by the Board of Health.
Signed �c�,t�Gl w��- 1fJ�Gli7 g� @yrT:r c Date
Inspections
No. �� " FEE
� - COMMONWEALTH OF MASSACHUSETTS # ()oo,lot
Board of Health, Y"Mc) try MA.
CERTIFICATE Of COMPLIANCE
Description of Work: IdIndividual Component(s) ❑ Complete System 4 �;Cv ^ 7 75-e
The ui dersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded( ), Abandoned ( )
by:, 6. T 3,our (n.
at 1 /q(o Ali
has been installed *0,accordance with the ovisi s of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. % dated Approved Design Flow (gpd)
Installer CY62-1-STht''iU" NZ. _Q0C�`7-.•_-, V_0&:gZX (3, 00. Z _
Designer: Inspector: .,,.v,nwyf Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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! 7 COMMONWEALTH LTH OF MASSAC14USETTS
Board of Health, () i , MA.
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DISPOSAL. SYSTEM CONSTRUCTION PERMIT
FEE Vim. 0
Permission is herebygranted to Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at I N6 fl -f e 2-6 as described in the application for
Disposal System Construction Permit No. IC-7 dated , — of
Provided: Construction shall be completed within three years of the date of this per 't. e 1 local conditions must be met.
Date Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, tin ' � � � Board of Health