HomeMy WebLinkAboutApp-Permit-ComplianceNo. _b'o— C? i L'/�I� FEE Wiz�
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C®MMONWELT14®F MASSAC14USETTS
Board of Health, I el -V VrDcx— , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Z_�4
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Application for a Permit to Construct( ) Repair pgradeO AbandonO - ❑Complete System ndhidual Components
Location' ! O
So- i
Owner's Name AH,-,
Map/Parcel#
Address,
Lot#
Telephone#
Installer's Name ��.�y��
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Designer's Name
Address ��iISTY 6�•1
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YS�b ►S
AddressC��'����f-
Telephone#
Telephone# � j -. V6,
Type of Building Lot Size /0 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder { )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required//) °A 0' gpd Calculated design flow Design flow provided y gpd
Plan: Date VY ✓&,1, Q Al, o�U%k Number of sheets 0 Revision Date
Title t
Description of Sbil (s) -,�u SSC_ /_ __—
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install a abo described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pla e s min operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. �i } �. C.c t - .a �� 1`i eC '4 E
COMMONWLAiLT14 OF MASSACHUSETTS z�
Board of Health,
Mtlk-af I)(—,-
CERTIFICATE
Of COMPLIANCE
Description of Work: 'Individual Component(s) ❑Complete System � ( ), Aba donj z ere
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired , Upgraded e ( )
at 'e .r_% P' d . .i A 1.47 7
has been installed i accord nce with the provisions ` 310 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No. ' dated` 1 . Approved Design Flow (gpd)
Installer '?'Y ., s i; t f� ! ' ,f� �f�-E-� . 7;..G
Designee Inspector: 1' Date:
The issuance of this permit shall not be congtrued as a guarantee that the system will function as designed.
COMMONWEATIJ OF MASSAC14USETTS
Board of Health,` I S i ! MA.
DISPOSAL SYSe. M CONSTRUCTION PERMIT
-- FEE
Permission is hereby granted to; Construct( ) Repair(Upgrade( ) Abandon( ) an individual sewage disposal system
at �, r i �~. i Y� e. as described in the application for
Disposal System Construction Permit No. ' Z'W , dated
Provided: Construction shall be completed within tiefg—ars of the date of this permit. V1 local conditio.pj must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. ChadWun, MA Date f L� "' /:. Board of Health / ( \