HomeMy WebLinkAboutApp-Permit-ComplianceONU LTH Of MASSACHUSETTS
Board of Health,) f49N6 , MA.
VOR.,DISBOSAL SYSTBi CONSTRUCT]
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PERMIT
Type of Building _ I�id P� co— Lot.Size sq. ft.
It
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) ,Cafeteria ( ):
Other Fixtures
Design Flow (min. requireD gpd Calculated design flow Design flow provided gpd
Plan: Date °�I o�y II 1� Number of sheets Revision Date
Title
.Description of Soil (s) ' A
Soil Evaluator Form No. Name of.Soil Evaluator -!t� -t' —MC G n Date of Evaluation L4 -1 I
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigne ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre to n to place thenm�grtion until Certificate of Compliance has been issued by the Board of Health.
Signed Date 't '2-10
Inspections
COMMONWEALTH Of MASSACIIUSETT
Board of Health, VAW)f , MA. .14
..r a
CERTIFICATE Of COMPLIANCE
Description of Work: vidual Component(s) ❑ Complete System
The undersigned herebycertify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ,Abandoned
`7_ (} '
by: 2,-7 l f 2ri,,7
at ~..._ 4 .^5 1 (:2,
has been installed 'n accordance with the provisions f,�310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applic.atioi N.o, g -' dated. �'� Approved Design Flow 1 � � � (gpd)
Installer j i J
Designer: ILIf aQNi l t C.r Inspector: fr' / Dater/
The issuance of this permit,shall not be construed as a,guaranpse that the system will function as designed.No. J
c ��•. y t t ........_. _t �� a 6 FEE _ J
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 1/6()]1+ MA.
DISPOSAL SYSTEM CONSTRUCTION-
Permission is herebygranted to; Construct( ) Repair( ) UpgradeV Abandon( ) an individual sewage disposal system
n �-t
at �_ l E j ; j E .. _ - (r 1 b as described in the application for
Disposal System Construction Permit No, .- dated
Provided: Construction shall be completed within three years of the date of this peri z . 1 local �cyond do s i st be met.
Form'1 s Re iss k. c A/ Date % % `*c Board of Health
% _._L 7 � /l �_�%.?/� u�d�U .112 J F: -1-A7- r--1 C,
/1..T1
Location c217 fa l
Owner's Name
o Map/Parcel# 5S
Address 2% a -
Lot#
Telephone# ) r) y - 23 7 _ 0� 9 C�
Installer's Name ���ja
Designer's Name �aG
Address "�'
Address-SO
'Telephone# SD 9 -7 _66,53
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Telephone# 5 D 9 -833--2
Type of Building _ I�id P� co— Lot.Size sq. ft.
It
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) ,Cafeteria ( ):
Other Fixtures
Design Flow (min. requireD gpd Calculated design flow Design flow provided gpd
Plan: Date °�I o�y II 1� Number of sheets Revision Date
Title
.Description of Soil (s) ' A
Soil Evaluator Form No. Name of.Soil Evaluator -!t� -t' —MC G n Date of Evaluation L4 -1 I
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigne ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre to n to place thenm�grtion until Certificate of Compliance has been issued by the Board of Health.
Signed Date 't '2-10
Inspections
COMMONWEALTH Of MASSACIIUSETT
Board of Health, VAW)f , MA. .14
..r a
CERTIFICATE Of COMPLIANCE
Description of Work: vidual Component(s) ❑ Complete System
The undersigned herebycertify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ,Abandoned
`7_ (} '
by: 2,-7 l f 2ri,,7
at ~..._ 4 .^5 1 (:2,
has been installed 'n accordance with the provisions f,�310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applic.atioi N.o, g -' dated. �'� Approved Design Flow 1 � � � (gpd)
Installer j i J
Designer: ILIf aQNi l t C.r Inspector: fr' / Dater/
The issuance of this permit,shall not be construed as a,guaranpse that the system will function as designed.No. J
c ��•. y t t ........_. _t �� a 6 FEE _ J
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 1/6()]1+ MA.
DISPOSAL SYSTEM CONSTRUCTION-
Permission is herebygranted to; Construct( ) Repair( ) UpgradeV Abandon( ) an individual sewage disposal system
n �-t
at �_ l E j ; j E .. _ - (r 1 b as described in the application for
Disposal System Construction Permit No, .- dated
Provided: Construction shall be completed within three years of the date of this peri z . 1 local �cyond do s i st be met.
Form'1 s Re iss k. c A/ Date % % `*c Board of Health
% _._L 7 � /l �_�%.?/� u�d�U .112 J F: -1-A7- r--1 C,