HomeMy WebLinkAboutApp-Permit-ComplianceNo. Cols —62fc AK111 1VI'ow / � '�'� _ ,7 FEE
COMMONWEALTH OF MASSACHUSETTS Ca 072Z
Board of Health, *4ND Lyk�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade�,,rAbandonO - ❑ Complete System-d<ldividual Components
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Location
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Owner's Name
Map/Parcel#
Address
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Lot#
Telephone#
Installer's Name
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Designer's,Name
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Address P ®-
DC��.i�
ddress
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Telephone#
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Telephone# Zo _
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Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms % %%- Garbage grinder {
Other Type of Building No, of persons Showers ( ), Cafeteria ( ).
Other Fixtures
Design Flow (min, requi ed) y l gpd Calculated design flow g l Design flow provided gpd
L) � Plan: Date LAJI Number of sheets ly Revision Date
Title
Description of Soils)
Soil Evaluator Form No.
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of Soil Evaluator AA �`/ 6N HDA)Q Date of Evaluation
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DESCRIPTION OF REPAIRS ORALTERATIONS ` O S"kt),
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of THE 5 and
further agrees to not to place the m in eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date &?Z/-QZ
Inspections
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No. y✓�� ��� 4�..41 Emstyre LIE
COMMONWEAL114 Of MASSACHUSET � CIZ 3 i
Board of Health, YAa M O UT k , -OA:
CERTIFICATE Of COMPLIANCE
Description of Work: O-Kdividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O; Repaired ( ),,Upgraded (-�;<bandoned O'
by Rn6e t°-i" v R. C _n A :'tea C
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) ande proved design plans/as-built plans relating to
application No. , dated .-� .7 �. Approved Design Flow (gpd)
Installer k -T o V a + Xl
Designer: Sa. S" nspector: Date:_��
The issuance of this permit shno be construe as a.gu r rte all e that the system will function as designed.
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COMMONWEALTH Of SSACHUSETTS 0 7 2Z�7
Board of Health, )(&g& Old 1 A , MA.
DISPOSAL. SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( )� Repair( ) Upgrade( —)'-Abandon ( ) an individual sewage disposal system
at �v + iq A Ve- (ou l i as described in the application for
Disposal System Construction Permit No. 11 < , dated fib L 1
Provided: Construction shall be completed withineof the date of this peru7t. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesiown, MA Dad U -)-1 ~f /� Board of Health 7� '(