HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE /(" / FEE 5-57, 00
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P ICATI®N �6OR ISP®SAI. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair�Upgrade( ) Abandon() - J2--6omplete System O Individual Components
Location
114 .111 aV Cr �� (�
Owner's Name
11C5rV(z (A A(L71 p,/
Map/Parcel#
1122- t o
Address 114
'24fv W L I L
Lot#
Installer's Name r,^� EXeAV[Iti/
Telephone# 7 (L 9-14 103
Designer's Name AN A S EAKn-lAl
Address
1 -5- S W c..1 41A LA CCPI
I Address
S - A< 1,J," -1 V(Q4
Telephone#
<cj,? 4 Z
Telephone#
Q2 i{ 2 �bs
Type of Building 9=5112 eA--TI41— Lot Size �3 .6 Q_5- sq. ft.
Dwelling - No. of Bedrooms (2 Garbage grinder ( )
Other - Type of Building /VoV No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow � Design flow provided gpd
Plan: Date / 2V I Is- Number of sheets Revision Date
Title D-16- f?Li,&y OF rw lirAt-,dtytk �,L..
Z scription of Soil (s) M d?y
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
P
DESCRIPTION OF REPAIRS OR ALTERATIONS AS '-(0 eQ tSIS'T Q1F ►A 1 A/n LT9A-(0 t2 30S V ' S
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The undersigned agrees to install a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to t to place to operation until a Certificate of Co pliant has issued by the Board of health.
Signed Date LL
r'
Inspections
No.W-DC {'Y ; t X411,
FEE �y- 00
COMMONWEALT14 OF MASSACHUSETTS � �,�/ ���53
r Board o Health,
f i/A1"�oI'11 Ivr�l. d1,L1,r
A 19J CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 0 Complete System �R,,,
0
The undersigned hereby certify that the Sewage Disposal System; Constructe aid Upgraded ( ), Abandoned ( )
by: A (/-/" ,1 N D40 A � SK P Af,) C0051RU M- t5 6J
has been instal ed in accordance with e p/h8visions of 310 CMR 15.00 (Title 5) an/d.the approved design plans/as-built plans relating to
application No. ��l dated -'l Approved Design Flow.4o.- (gpd)
Installer I( ?' ; � of twr L � C ,1 k./.4 14.. x'.+ CP
Designer: Inspector: Iy Date: ,
The issuance of this permit shall not be construed as a guarant ; that the system will function as designed.
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No. 60 ��""?i g� 'DA -t-)
DA -t^) A. 30 r-mAw t.t 05T-9• FEE ..00
/
COMMONWEALTH OF MASSACHUSETTS X013
Board of Health, YAgMO VV , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair(X Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. �dated
Provided: Construction shall be corhpleted within thfee- pears theate of this permit., All local condi o must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslow MA Date / B; So d o Health pt
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