HomeMy WebLinkAboutApp-Permit-ComplianceNo. n vL-b -iQ -oQY'%tis FEE'
Bo RDC-I9-2 -Z9i COMMONWEALTH OF MASS CHUSETTS G 27-13
6 6 Bovril ofIlealth, y;UMQUn+ , MA. ��'' 14
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade AbandonO ❑ Complete System Individual Components
Location `U
l wP/
Owner's Name
Map/Parcel#
3
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Address 10 y3 �P%//�Pb-G� �`�/'j"iG�/
Lot#
Telephone# So 3 G 17
Installer's Name G '
cc pts-1-
43rd rAed
Designer's Name `Cq GI
Address Aj
a.S&"3-i/y►-----.�
Address Quh�'Zp
Telephone#
(Q44-3
Telephone# 'o '�7s�-. d ri
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 4 Garbage grinder
Other - Type of Building No. of persons Showers O, Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow providedgPd
Plan: Date -S qh nJ) . an Number of sheets , Revision Date
Title
Description of Soil(s) S—e-e soi I , 0 4
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS L -e t 4 l� I(4r4h u S Ti aP 1 11-rti "-v H icy b
��� c�j �� hg /S�►� spa. N �p ��a- 9�►- Q- 6,4 ,f as Y r
Si F/tiK o"1 C' e`nl�� d1G w, l�.r 4 1 La-"'r., —> 1 e+ r r r`el �P /S� r l �zp ,.GPI 41-W
The undersigned agree, ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o pinc the s�gtte p o' til a Certificate of Compliance has been issued by the Board of Health.
Signed - Date
Inspections
No. L% f !'- FEE��
COMMONWEALT14 Of MASSACH TSETTS
Board of Health, �14dD , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ,,Individual Component(s) ❑ Complete System' T�
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned
at oo d-p''-e f. i. is 'r 1 - f `) l �r o
-11
has been installed it}�accordance with the provisions of 3110� CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No. Y 6 dated t 8� Approved Design Flow+4�gpd)
InstallerQe
Designer: ; ? ; 1 ! ; v .-l:1 r r 5 l Inspector: a`rr r �`n+� z Date:
:.5-eL-
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. C� 1 C'.0 1 - �Ze7 EL-. -j ` i' il-Q � FEE
r
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Vaemat mi MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(. -'"Abandon( ) an individual sewage disposal system
at 0 0 Axi I(. YO -e�-e I / r: { i ; f' ��r i %�: �c'' r/ yas described in the application for
Disposal System Construction Permit No , dated '7
Provided: Construction shall be completed within,
ee r` a date of this pe nttl 411 local con jtions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA D'ate'7. lam! ! 4 Board of Health