HomeMy WebLinkAboutApp-Permit-ComplianceNo. Al O C FEE' W `�
C® ®NW LTH Of MASSAC14USETTS � l�
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Board of Healih, Y l ±i�.� (� MA. '
P ILICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(' ) Repair( ) Upgrade$kAbandonO ❑ Complete System *Individual Components
Location apo -Buc v- 3-s1 (4A '..-A
Owner's Name 0v5 2 01-1 c p(L+(�t
Map/Parcel# " 9 c (�(o (o
Address 3oc) G� -S,5 � 1� lLo A�
Lot#
Telephone#
Installer's Name'
D esi ners Name 1
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Address 'S 3 l� ✓Y1 { d� C.1� S ��
Address
Telephone# ;-0ICZ - 14-1'1 ZZ
Telephone# 3 S (p
4
Type of Building (_ to d1 So Lot Size oo sq. ft.
Dwelling - No. of Bedrooms C �= l 41'lT Garbage grinder
Other - Type of Building No. of persons Showers( ), Cafeteria (
Other Fixtures
Design. Flow (min. required) O ?D gpd Calculated design flow Design flow provided _ gpd
Pian: Date O" 3 2 0 i b Nu^mber of sheets �— Revision Date
Title 3 o n a a�e.l t_ �y5 1,4 1 [ ft—a-A -VIA &
Description of Soil (s) l4�1
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 20 3 0o0 G't &L- 2 Co "'` P p �'T�' `Q�✓t'1 2�J HZ T�'►'L K'
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not lace a system in operation until a Certificate of Compliance has been issued by the Board of Health..
Signed Date 20 O
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No.^ "� FEE,
C®I� MONWEALT14 OF i SSACHUS ETTS c � _ r ��� : � a
Board of Health, -YA,
eaQ , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System Constructed ('), Repaired ( ), Upgraded, Abandoned ( )'
by:
at " '�c�� moi= 1C� k `� i c� 4D 'C'
has been installed in accordance with the provisions of, -V.0 CMR 15.00 (Title 5) and the
approved design plans/as.-built plans relating to
application N'. J ,dated /t' Approved Flow � ,T_(gpd)'
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Installer �A 1l r C
•g - - L. Inspector: r' ✓� _ Date: rl:; -► "—�" Designer: 1-1 �� 1 �,�.... , c;,,�.�,; inc , d
The issuance of this permit not be construed as a guar . ee that the system will function as designed.
No. FEE _
= ,
COMMONWEALTH OF MASSACHUSETTS �- = 12
Board of Health, Yi31ZA4 6 C. n+ MA.
DISPOSAL SYSTEM CONSTRUCTION_ PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
at to ,D J T?� �1 t as described in. the application for
:1,
Disposal System Construction Permit No. �t� � dated`
Provided: Construction shall be completed within three years of the date of this permit. 1 local conditions must be met.
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Forts 1255 Rev. 5196 A.M. Sulkin Co. ChadeStOwn, MQ- Date, � � _ hoard of Huth
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