HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 prU —
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of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade . Abandon( ) - lete System ❑ Individual Components
Location _
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Owner's Name f',k 9-j e
Map/Parcel#
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Address /rc/
Lot#
Telephone#
Installer's Name Gyp Clq k_e Aevw �+ ,��
Designer's Name. �,p �� I S
Addresses ,
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Address �, • ��� r�
Telephone#
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1 Telephone# -50,r 7 - Y /
Type of Building
Dwelling No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (mina required) '4/yo
gpd Calculated design flow '-/yL
Plan: Date / �/ Number of sheets i
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided '1' 141 gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -TM �+' t / / S-yc3 S' A/ 101+ � �. P /, %�? k • �>�
116 �'_ '�rSta�► �v.�►6A) -50y,- 111S ��t1 � L G- 6-XZ.46-14� nT C414M> A<,
The undersignedjaere to install the bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees place th em in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date /1Z / /?//. I
Inspections��
No. FEE.
Board of Health, .M6 , ALA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (off, Abandoned ( )
by: r74 ,4" ^ / g4l 4 e ��� C r3P je- As LA
at%/►: n9ls9 P rE S�
has been installed in :ace dance with the provisions of 3110� CMR 15.00 (Title 5) and/ t proved design plans/as-built plans relating to
application�, No. dated �"' 2- �f '-� ./Approved Design Flow _-1''�(gpd)
Installer <-4c3 C.. -� i !
Designer: Tt° Pt .'l �Q. rlA fi�� Inspector: iR � Date: k
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 3 +t ( ` - (a ' o i C k(2-"? tJ A-(_,, FEE
Board of Health, A&M mm,` , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (-, Abandon ( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. % dated
Provided: Construction shall be completed within �� f he date of this permit l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date /- %-/B rd of Health
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