HomeMy WebLinkAboutApp-Permit-ComplianceNo. Sad DC—Iq-4St6 [fr? } � 14,,.E / %� , r FEE -55_
COMMONWEALTH SOF MASSACHUSETTS OV 11
P Boa)d of Health, Y49Jw16 MA.
APPLICATION FOR DISPOSAL SYSTEM L CONSTRUCTION PER
Ar, Aication for a Permit to Construct( ) Repair(+) Upgrade( ) Abandon( - ❑ Complete System ndividual Components
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oration 5.7
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Owner's Name ^j 1 m 3t;L-L(1,,
ap/Parcel#
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Address
Lot#
Telephone#
Installer's Name
go beer 3 ,.r C0ZCYkL
Designer's Name
Address—t
Address
Telephone# 506-509-q0 '!j
Telephone#
Type of Building
Dwelling - No. of Bedrooms,
Other -Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No
gpd Calculated design flow
Number of sheets
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ��(7 -!" 6Ch L10 & Pe 1"iD-/^ OV461`l,k- t-� !&Vf e
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
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further agrees to not to lace t e sys em in operation until a Certificate of Compliance has been issued by die Board of Health.
Signed i).l�r Zk1X i, @2C /Y,Date I-" Zq—%q6
Inspections
No �2,6,,}-I c--lt`1--i wi t(' PCL
COMMONWEALTH OF lA SACIIUSLT TSS
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Bor! aq-IQ...,66LFo(I�
r t rardofl-L:a1,Eh, MA.
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CERTII~ICATIu Of COMPLIANCE
Description of Work: (fl`Individual Component(s) ❑ Complete System ,S e"•^+ ;� 11'
The enders igned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired 61,11' Upgraded ( ),Abandoned ( )
by: ut^t}I`i:.,l..,.l.` ' X*'f" f1°" 7Y V
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.
„ 1'`� ' dated s -- � '"'✓`YApproved Design Flow (gpd)
Installer �t a k art"r."'- rT^�', F t 4"' t^ p=t'"pn' �...
Designer: "" Inspector: �f r +o-,�6a� t'r!,t., Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. e) 0, Pr I)['..-{t'j --d' IC, .j ps" � l}��''�_ FCC ,.d ("",.,. t'}i
v LOOl�e) IALTII 0F MASSACHUSETTS
Board of Health, A41 i' h 1,! T" 4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair(VI' Upgrade( ) Abandon( ) an individual sewage disposal system
at b5 Es e f ka3f:"1F�d as described in the application for
Disposal System Construction Permit No. f -. , dated
Provided: Construction shall be completed within -three"" at& 'of -the date of this permit. All local conditions must be met.
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Form 1266 Rev, 5196 A.M. Sulkin Co. Chsrreslavn, MA Dace C ' � $02lyd Of Health.
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