HomeMy WebLinkAboutApp-Permit-ComplianceNo. 00 "C Lia `�'`' U FEE
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COMMONWEALTH Of MASSACHUSETTS cumvez,
Board of Health, Y&9MOUTI+ , MA.
APPLICATION FOR ISPOS L SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( O UpgradeO Abandon - LlComplete (System (In-dividual Components.
Location i
Owner's Name TY) i .Oe_
Map/Parcel#
Zl , (i
Address A n ` L-1 1 t
Lot# ��'
Telephone# tcg -7140— C9 l
Installer's Name
C S C� _
Designer's Name r.
Address1
l�� MG
ddress 1PC7 1 r
Telephone#
Z CSC
Telephone# - 044-C?Qt-l�R
Type of Building t"l�' c� �e i�i�—� .� Lot Size rs sq. ft
Dwelling - No. of Bedrooms Z . Garbage grinder {
Other - Type of Building No. of persons Showers O, Cafeteria
Other Fixtures
Design Flow (min, required) Z2 -c) gpd Calculated design flow ?--Z4D Design flow provided :3' gpd
Plan Date Number of sheets Revision Date
Title
Description of Sroil(s)
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned ll the ahoy d seri dual Sewage Disposal System in accordance with the provisions -of TITLE 5 and
further agrees t noteee system ' o a Certificate of Compliance has been issued by the Board of Health..
Signed Date
1�
No. ti.
FEE
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COMMONWEALTH Of MASSACHUSETT •
Board of Health, 0} MA.
CERTIFICATE OF COMPLIANCE a
Description of Work: ,Q46dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ); Upgraded ( ), Aba�done <( )'
at
has been installed ii-i,*ccordaTice with the provisiorr i -of R CMR 15.00 (Title 5) and thea proved design plans/as.-built plans relating to
application No. , dated Approved Design Flow (gpd)
Installer 'r r 't^ '' 7 i _. vi.. � ZE/
Designer: Inspector: ! Dater P
The issuance of this permit shall not be construed as a guar�tht e system will function as designed.
No. �.- ci �4a ( �: f'.�r. �C� , f J�'. FEE �. _..
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, yAlem to Lm "
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to Construct( ) Repair( ) Upgrade Kj Abandon( ) an individual sewage disposal system
at 11 IIIJ 0 �>(,W Q
as described in theapplication.. for
Disposal System Construction Permit No. b dated
Provided: Construction shall be completed within three years of the date of this permit..,)„local conditions t be met.
Form 1255 Rev. 5/96 R.M. Sulkin Co. Chadeslown, MA Date ”- Board of Health/ ��-t- LAle---z