HomeMy WebLinkAboutApp-Permit-ComplianceNo. a*DC- 8- '1 `� / '��'/ �/G/� / FEE .�
COMMONWEALTH OF MASSACHUSETTS
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Bo'YA-P-MQ JM MA.
red of Flealth, ,
APPLICATION FOR DIS POS�I ��T 'I CONSTRUCTION PERMIT
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A plication fora Permit to Construct(t/RepairUpgrade=- - Complete System ❑ Individual Components
Location
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Owner's Name
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Map/Parcel#
Ooo,2-5-7
Address
Lot#
Telephone#
Installer's Name �V f
Designer's Name
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Address
91 �Li ✓ieo .�i, ,E '/e(lajVi�
A Address
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Telephone#
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Telephone#
Type of Building Lot Size, _ sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder
Other - Type of Building, No. of persons Showers ( ), Cafeteria
Other Fixtures l
Design Flow (min, required) a gpd Calculated design flow Design flow provided3 `/ gpd
Plan: Date Number of sheets Revision Date
Title
Description of:Soil .(S). q.
Soil Evaluator Form No. Name of Soil Evaluator J& Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS /4���I%tf�l��� �-� 6✓/ A� /1
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with theprovisions of TITLE 5 and
further agrees to not to ace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed A Date /0, 12.- )
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No. i% G " C J FE) �° 5 , 00
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COMMONWEALTH OF MASSACHUSETTS. o'�-o ��
Board ofHenitls, ��}►2.�.1C1 MA,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) W'Complete System
The undersigned hereby certify that the Sewage Di Fosal System- Constructed ( ), Repaired ( ) , Upgraded (%4,-iY6andon•ed
by;%%�i
at
has been installed ' i acco nce with the rovisions of 1.0 CMR 15.00 (Title 5) and e a�i� owed design plans/as-built plans relating to
application No. r�`.. dated— Approved Design Flow 'T" (gpd)
Installer
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Designer: C—) -)410G L�,r4� Inspector: , . Date: r
The issuance of this permit shall not be construed as a guar tee, that the system will function as designed.
No. b o 0 U c" i —022 7 u + FEE +
- -- COMMONWEALTH OF MASSACHUSETTS (Or, 0
Board of Health, YA Lrm, MA.
DISPOSAL S1 M CONSTRUCTION ��RMIT
Permission is hereby granted to;, Copstruct(u') Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
i
at r f as described in. the application for
Disposal, System Construction, Permit No. to 2 , dated, 7 %.
Provided: Construction shall be completed within44P48Wbathe date of this permit All local conditions-pnust be met.
Form 1255 Rev. 5196 A;M,Sulkin Co. ChadeStown, MA Dat Board of Health