HomeMy WebLinkAboutApp-Permit-ComplianceNo. 'bo"c—lq- 277
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Board of Health, o on MA.
APPLICATION F® DISPOSAL SYSTEM CONSTRUCTION PERMIT
i3lAp lication for a Permit to Construct( Repair(") Upgrade O Abandon - El Complete System C�Individual :Components
" ,ovation CoCJ�. UVtG Owner's Name M Art Z' ef
Type of Building u_n L1 W1 p Lot Size sq. ft.
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 Des ign'flow provided gpd
Plan: Date Number of sheets _ Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The unde ign d agrees to install the above described Individual Sewage;Disposal System in accordance with the provisions of TITLE 5 and;
further at�oe
lace the system in operation until a Certificate of om " ance has been issued by the Board of Health..
Sighed Date 3 1"L
Inspections.
No. 6044 C A
-(�- ! / < J..l�%f 11FgE CJs,,6V
COMNIONWEALT14 Of MASSAC14USETTS
r`9 7 )/"mown-► MA.
Board of Health, ,
CERTIFICATE OF COMPLIANCE
Description -of Work: ®'Individual Component(s) ❑ Complete System
The undersigned herelly that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded( ),Abandoned {
by
at
has been installed • cc dice with the r0l.sions o0 CMR 15.00 (Title 5) and the:approved design plans/as-built plans relating to
application, No. �Ci dated _/91 Approved Design Flow �- (gpd)
Installer lei //
Designer: Inspector: Date:: � F
The issuance of this permit:shall not be construed as a ga tee that the ystem: will function as designed.
No. '"I G�"' .fi ! / Q � Q �j C�V FEE 66,00
. COMMONWEAI.TII ®f MASSACHUSETTS
Board of Health, Ywmoun' ,1VIA.
DISPOSAL SYSTEM[ CONSTRUCTION PETIT
Permission is, hereby granted to Construct( ) Repair( Upgrade.( ) Abandon( ) an individual sewage disposal system
at_. C0\/G11 gA --1 // as described in the application. for
Disposal System Construction Permit No. t dated J
Provided: Construction shall be completed within _ of the date of this DIUit. All local cop d' 'ons must be met.
Form 1255 Rev. 5/98 A.M. Sulkin Co. Chadestown,MA Dater")? Board of Health
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Lot#
Telephone#
Installer's Name �
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Designer's
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Address1
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Address
Telephone#
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Telephone##
Type of Building u_n L1 W1 p Lot Size sq. ft.
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 Des ign'flow provided gpd
Plan: Date Number of sheets _ Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The unde ign d agrees to install the above described Individual Sewage;Disposal System in accordance with the provisions of TITLE 5 and;
further at�oe
lace the system in operation until a Certificate of om " ance has been issued by the Board of Health..
Sighed Date 3 1"L
Inspections.
No. 6044 C A
-(�- ! / < J..l�%f 11FgE CJs,,6V
COMNIONWEALT14 Of MASSAC14USETTS
r`9 7 )/"mown-► MA.
Board of Health, ,
CERTIFICATE OF COMPLIANCE
Description -of Work: ®'Individual Component(s) ❑ Complete System
The undersigned herelly that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded( ),Abandoned {
by
at
has been installed • cc dice with the r0l.sions o0 CMR 15.00 (Title 5) and the:approved design plans/as-built plans relating to
application, No. �Ci dated _/91 Approved Design Flow �- (gpd)
Installer lei //
Designer: Inspector: Date:: � F
The issuance of this permit:shall not be construed as a ga tee that the ystem: will function as designed.
No. '"I G�"' .fi ! / Q � Q �j C�V FEE 66,00
. COMMONWEAI.TII ®f MASSACHUSETTS
Board of Health, Ywmoun' ,1VIA.
DISPOSAL SYSTEM[ CONSTRUCTION PETIT
Permission is, hereby granted to Construct( ) Repair( Upgrade.( ) Abandon( ) an individual sewage disposal system
at_. C0\/G11 gA --1 // as described in the application. for
Disposal System Construction Permit No. t dated J
Provided: Construction shall be completed within _ of the date of this DIUit. All local cop d' 'ons must be met.
Form 1255 Rev. 5/98 A.M. Sulkin Co. Chadestown,MA Dater")? Board of Health
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