HomeMy WebLinkAboutApp-Permti-ComplianceNo. O O"Y`Al -0-2- 7 13 0 -rR-
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COMMONW%%9&W�/�1i.. i
QJUSETTS
Board of Health, 1148 ROUTE 28/>- MA.
APPLICATION f'®R DISPOTA"MiP,-,UCTION � I�l[9[IT V
Application for a Permit to Construct( ) Repair( .) Upgrade( Abandon() - U Complete System Individual Components
Location 191
(LLE *A
Owner's Name C "
Map/Parcel#Address
9 a C
Lot#
X7
Telephone#
Installer's Name (2APE f
Designer's Name -T L SU L
Address
C� ,T
Address as -5!E
Telephone#
sd1�,� C�Z"L .- 'fig 7
Telephone# 5ai -x-73 -
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size `;Lj:8(3! sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 33 gpd Calculated design flow Design flow provided .349. gpd
Plan: Date t6-(1- X01 SZ - Number of sheets 1 Revision Date
Title %L C LOIR 6RaQ[K�Ab Weg-i VARIa0u- -4
Description of Soil(s) 't6-DlbGat s it�Ca k are 7>L 41C)
Soil Evaluator Form No. Name of Soil Evaluator I9d1rk1TE- Date of Evaluation I'D - 4- X0Lam'
DESCRIPTION OF REPAIRS OR ALTERATIONS U56 GYL I / i.,<- I i 000 expFL L.I� -50r -- T1WK-
-CZ�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to notto place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 40 -15 I
Inspections
No. 11-t C -4 l — 0 2 l ^7! FEE4-55
Q tJ
COMMONWEALTH Of MASSACHUSETTSV 7
Board of Health, AR 4ovTYCERTIFICATE Of COMPLIANCE
Description of Work: U Individual Component(s) U Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (L , andoned ( )
by: MITE
at '7 C& F11 -4J
has been installed in accordance with the provisi ns ofA10 CMR 15.00 (Title 5) and ap oved design plans/as-built plans relating to
application No. _ dated / (� �.�.� /�1S Approved Design Flom (gpd)
Designer: ZC- EM& A)QaKi&A,- ZUL Inspector: Date: AV
The issuance
` of this permit shall not be construed as a guarantee that the system will function as designed.
No. 120i� D C-1-8 �� 0 -7 CAW &3 FEE . Lb
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, Yd AM oVi MA.
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade (e--4 '�bandon ( ) an individual sewage disposal system
at o�. G('tZ1���G as described in the application for
Disposal System Construction. Permit No. �'.� , dated
Provided: Construction shall be completed within tla eaXithe date of this permit
jA5j" local condition�ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date f J �4 ~ (Board of Health
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