HomeMy WebLinkAboutApp-Permit-ComplianceNo. &VMr `�R6 /� / .. `�.-� 0 ��� FEE O' ��� 06
COMMONWEALTH OF N][ASSACITiJSETTS OV71
Board of Health,Mo , MA.
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APPLICATION FOR DISPOSAL SYSTEM C®NSTRUCTI PEWT
Application for a Permit to Construct( ) Repair( ) Upgrade �andon ( ) - ❑ Complete System �idividual Components
Location 3
er's Name 49b J_.Z
Map/Parcel#
46) 7
Address S `e_
Lot#
Telephone# S d '7 7(p 7 L-�C, Alcjlrti
Installer's Name
1I1 t s /Jlw]?1+- s C�
Designer's Name lot417/L �h SG�i7/✓G��
Address�✓
Address a �3 SO, 0 4
Telephone#
S'c- (p
Telephone# Sp �"� t� tl 371
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
No. of persons
Lot Size sq. ft.
/10 Garbage grinder( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date -*c,'1 i 1 0`0) Number of sheets Revision Date
Title
Description of Soils) S4e JOS' 10�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DE,,CRIPTION OF REPAIRS OR ALTERATIONS SO
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o ac th tem ' a on a Certificate of Compliance has been issued by the Board of Health.
Signed `/ Date �� 1 X41
e
No. AEV 00
COMMONWEALTH Of MASSACHUSETTS 7)1111
-3 7 of Health, i!/%Y�t�(i�}{ , MA.
CERTIFICATE Of C®MPLIANCk ¢��P� ��`�� �j �� �`� 7,
i Description -of Work: �dividual Component(s) ❑ Complete System / / / j S i
The undersigned hereby certify that the Sewa a Disposal System; Constructed ( ), Repaired ( ), UpgradeddAbandoned ( )
i
at > � to, C%�, ►/)-P /�,% 9 LAS ;• �.�t • --- ���-- /?'1. �j
has been installed ina cod red ta,�,g' with the provisions of 3CMR 15.00 (Title 5)and the design plans/as-built plans relating to
application No. dated ~� r Approved Design Flow (gpd)
Installer 11--/),S 03 G % Q'J C. C - 7 J' r, s l ,r
Designer: i) /i 1)C l:l ! St'C. Insfector: _a' t Date:
The issuance of this permit shall not be construed as a guar a that the system willfunction'as designed.
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No. �'(! C :r , �1 (0� S V.2 t�-.t`� S FEE
7 COMMON LTH OF MASSACHUSETTS c' ��7
Board of Health, ZjY 0VT_4 , MA.
'DISPOSAL SYSTEM C®NSTRIJC-ON PERMIT
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Permission is hereby granted to; Construct( ) Repair( ) Upgrade(" Abandon( ) an individual sewage.disposal system
at e `. ` �~ t7 '" �^� -''i ` '' G`' ' ,meq as described in the application for
Disposal System Construction Permit No f `� , dated 2 -' i r
Provided: Construction shall,be-completed`within three years of the- date of thts perm , All local condi'd ns must be met.,,,,
171 i /:
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA DateG ,:.Z"� 11 Board of Health ,/ ? 'f t� �•-- .