HomeMy WebLinkAboutApp-Permit-Compliance19 -OO u 0-7 -2
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COMMONWEALTH OF MASSACHUSETTS
85T- 73-7 -1078
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Constrict( ) Repair( ) Upgrade( ) Abandon( ) ❑'Complete System q Individual Components
Location 11,--r
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wner's Name
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Lot Size .2-1 0(0ft
Nola p/Parcel# Ac, 3
19e L O. i-6
Address
Lot# ct
av, MAI
Telephone#
Installer's dame
Designer's Name n tj
t cox
Address �j 3 �i
Address ' A
I
Telephone# 1 _ 4 2 ---Lc, -2-o •
Telephone# 2SS
9-312,
Type .of Building I�
E
L` i _ _
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Lot Size .2-1 0(0ft
Dwelling - No. of Bedrooms
3
_ Garbage grinder. ( }
Other - Type of Building
No. of persons Showers ( ); Cafeteria.
Other Fixtures
Design Flow (min. required)
s S O
gpd Calculated design flow
Design flow provide S c gpd
Plan: Date SA ,,J l2 2-01
-1
Number of sheets _ Z
Recision. Date
Title
Description of Soil (s)
SA
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The: undersigned agrees to install the above described Individual Sewage;Disposal System. in accordance with the provisions. of TITLE 5 and.
further agrees toltem in operation until a Certificate of Compliance has been issued by the Board of Health.
a SignedDate 2 -Z1 i �•
COMMONWEALTH OF MASSACHUSETTS
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Board of Health, YA aW M , MA h
; �4CE. IIFICATE OF COMPLIANCE
Description of Work:ndivfdual Componenc(s O Complete System
The undersiggned hereby ce;ttfy 'that the Seage Disp $o'1',Sysrem; Construe
The { ), Upgraded ( ), Abandoned
by: N ��t X G1J,V A`il0 ;J s
at
has been installed' accord nce with the pro�asi tas of 310 :CMR 15.00 (Title 5) and thea proved; design plans/as-built plans relating to
application No. dated. Approved Design Flow- (gpd)
Installer -i1k'0 l ti i"� E1 J b
Designer: elz + 4 L -Cox Inspector: Date-
No. -
ate
No. e2 0V" C
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, V AM-AW4 NM.
DISPOSAL SYSTEM CONSTRUCTION. PERMIT
FEE10, 00
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Permission is hereby granted to; ConstrucW11,Repair( ) Upgrade( } Abandon( ) an individual;sewage disposal system
at ..- d`+SS iZ-1y�.- .PA 12iC 1 �� `fi� as described in the application. for
Disposal System Construction Permit No,/'f- , dated
Provided: Construction shall be completed withfii4&4 94 the: date of this pe it. All Jocal conditions must be met.
Form 1255 Rev. 5/96: A.M. Sulkin Co. Chadesto n, MA Date- Board of Health
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