HomeMy WebLinkAboutApp-Permit-ComplianceNo. �d WD g b f 19, 00 44 d (to FEE 6 00
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�QNMONWEALTH OF MASSACHUSETTS ck#1674
66 1/
l Board of Health, )T MA.
�PLICATION FOR DISPOSAL SYSTEM T M CSN T UCTI�N MIT
Application a Permit to Construct( ) Repair( ) Upgra ) AbandonO -' U Complete System El Individual Components
Location 76 z -o- fb,
Owner's Name P,9 e--e.K_
Map/Parcel# Z
Address
Lot#
Telephone# `
Installer's NameLC n �De J n
Designer's Na�mse
Addressi -{4 a�4� lir n��
Address 46
Telephone#
Telephone# 7 / r 2zU
T e of Building Y
Dwelling- No. of Bedrooms
Qther - Type of Building
ther Fixtures
esign Flow (min. required) �� b
Pan: Date — / -
itle
escr prion of Soil (s)
Soil Evaluator Form No.
ki
No. of persons
Lot Size sq. ft.
Garbage grinder(
Showers ( ) , Cafeteria
gpd Calculated design flow Design flow provided17 gpd
Number of sheets Revision Date / e, 5 111z 23
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The un!ag;4re
4afes to ' tall a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further p _ce system in operation until a Certificate of ompllance has been issued by the Board of Health.
Signed Date Z ( l(�
.Inspections
No. COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA. .3
CERTIFICATE OF COMPLIANCE 41
Description of Work:; ❑ Individual Component(s) eComplete System
The undersigned hereby certify th4it the Sewage D'sposal System; Constructed O, Repaired ( ), Upgrade4
by: / /� r 4 / A ( �� G
at rZ,7
has been installed ii ccord ce with the provision
application No., j dated
1107
Installer A ' r'eV
Designer: ! !J , _ Inspector: 4144,r' Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ri C` C �• — a� I 1 ---_
COMMONWEALTH Of MASSACHUSETTS
s oft d CMR 15.00 (Title 5) an thea moved design plans/as built plans relating to
f Approved Dgn Flow (gpd)
Board of Health, �,$(L (} , AM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE P
J � 52Ll
Permission is erebygranted to; Construct( ) Repair( ) Upgrad E ( Abandon ( ) an individual sewage disposal system
at l� as described in. the application for
Disposal .System Construction Permit No. K '� � ,dated
Provided: Construction shall be completed within three years of the date of this perinit._, -11"l conditions nit�t be met.
Form 1255 Rev. 5/96 A. . Sulkin Co. Chadeslown, MA / Date Board of Health % ✓
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