HomeMy WebLinkAboutApp-Permit-ComplianceNo. O 1't`+/v". 11� 1QJ ;��lf/����'VPv /Ik�- /� FEES
COMMONWEALTH OF MASSAC14USETTS a-*055(0
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����ard of Health, ��rrzz�7EG�
APPLICATION
FOP DISPOSAL SYSTEM CONSTRUCTION FERMI
Application for a Permit to Construct( ) RepaitUpgrade( ) Abandon( ) - ❑ Complete System .ld'lndividual o �p nts
Location v
Owner's Name
Map/Parcel# �t��
Address - r el
Lot#
Telephone#
Installer's Name Cre'e'2 �6
Designer's Name
Address
Address,
Telephone# off_
Telephone#
Type of Building ,,:il ;69& Lot Size
Y6-4c sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) �i ,d gpd Calculated design flow
Plan: Date 8 Number of sheets
Title
Design flow provided 3i�. T gpd
Revision Date
Description of Soils)-/��'o•� �S6 4-5�dz 3c r
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS [ 'Ks.X?// _� c� .✓%-/�oX �� v� J C7CP
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to rwt to place the system nation'until a Certificate of Compliance has been issued by the Board of Health.
Signed /�--��L=4J Date
r P r; , � /e 1 �% %/rlI/4 1 / �/ % r .�f rat / G t' 'i . // /� K /1ilt1/'!'
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No. E d/
Board of Health, MA. i
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) � omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ((pgraded ( ), Abandoned
by: , --' u�?�i« .a-" per% �' -r cr— -5
at 3/ 'e' ,mr .- �{-`---
has been installed i accordance with the prov/isi s of 10 CMR 15.00 (Title 5) and the approved' design plans/as-built plans relating to
application No. / , dated C/ '" / % Approved Design Flow (gpd),
Installer
Designer: L._//�? Inspector: A"A�- t Date: y
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. Qtt C'1`'Oi�J Ci E coo) se t 1C. SVCS FEE
'-2- COMMONWEALTH Of MASSAC14USETIS
Board of Health, r-.'G� , MA.
DISPOSAL
Permission is hereby granted to; Construct( )
at
M CONSTRUCTION PERMIT
(Upgrade ( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. dated. ,, , -•-l0
Provided: Construction shall be completed withf the date of this permit. All local cp ditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA DaterCBoard of Health
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