HomeMy WebLinkAboutApp-Permit-ComplianceNo.Alef
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COMMONWEAL`
O ONS L` 1 MASSACHUSETTS ��s7�
,// d of Health, G f D MA.
APPLICATION FOR DISPOSAL SYSTEM ST CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad AbandonO - ❑ Complete System .OZndividual Components
Location tjjs
Owner's NameTIQ„ 4. , L/p1110
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Map/Parcel# c� J' (O
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Address i z ELT Z ML)S K 1 Tc
Lot#
Telephone# /) l) - 9 g y - f
Installer's Name 8-t P ekrn n
Designer's Name f G I S
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.Address (
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Address 5 7 2fcLA i czn S
Telephone# Jr _
Telephone# j 0 k- C4 --] QV
Type of Building �s-t�,n �-� Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafe�ia
Other Fixtures
Design Flow (min. rewire) -2 gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil
Design flow provided gpd
Revision Date
Date of Evaluation
The undersigned agrees to nstallthe above described Individual Sewage Disposal System in accordance with the provisionsofTITLE 5 and
further afir�e tl st min operation until ,a Certificate of Compliattce has been issued by the Board of Health.
Signed Date -7-2-1,4 %
4
Inspections S12I10 &pjs
No. FEE
COMMONWEALTH
MMONW LTH OF MASSACHUSETTS
Board of Health, i + / ; , , {, = MA. i.91 It(,
CERTIFICATE OF COMP IANCE oo��
Description of Work: C IW&vidual Component(s) ❑ Complete System e�
The!undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired { ); Upgraded ( Abandoned ( }
by: i
has been installed iu accordance with the provisions/o I ] 0 CMR 15.00 (Title 5) and the -approved design plans/as-built plans relating to
application No. _ £ !�i dated '" Approved Design Flowery. (gpd)
Installer _ r , i (. ,7 i , t 1_1�s�71:°
Designer: .:. r }..i Y ' iffc Inspector: �41419•� :59 ' i 0"_ / : Date; *- Q . t; a
The issuance of this permit;shall not be construed as a guarantee that the system will function as designed.
No.p��C'!'i� P FEE
COMMONWE-A 14 Of MASSACHUSETTS
Board of Health, J ` , MA.
DISPOSAL SYST M CoNSTRUCTIQN_ PERMIT
( Construct( ) Repair( ) Upgrade (� Abandon ( ) an individual sewage disposal system
Permission ishereby ranted to; i '
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at 1 t 1 �` '_ ; ;t .t' C_! S�i ,� t j r 1 1, _ (�,t..� J t t as described in the application for ;
Disposal System Construction Permit No. F
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Provided: Construction shall be completed within tl y trs of fhe date of this perani All local condi' ns must be met.
Form 1255 Rev. 5/96 A,M.Sulkin Co. Chadesiown, Mn Date. J / ) 7 '"$Gard of Health ✓�t.�7.