HomeMy WebLinkAboutApp-Permit-ComplianceNo, 01t / G✓�� FE " S425_100
OMMONWEALTH OF MASSACHUSETI
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PPLICATION FOR DISPOSAL SYSTEM CONSTPITCTION PERMIT
Application for a Permit to Construct( ) Repair( .) Upgrade{�bandonO TComplete System ❑ Individual Components
Location / z?V,#U
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Owner's Name �A
Map/Parcel# r
Address
Lot#
Telephone#
Installer's Namner's'Name
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Address ' &
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Address C-1 �Pr
Telephone# ® _ ;Vzo,
Telephone#SQoa _]
Type of Building S�i �G.J C -e— Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers O , Cafeteria ( )
Other Fixtures
Design Flow (mirl. required) Z� gpd Calculated design flow Design flow provided' gpd
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Plan: Date `/ Number of sheets ® Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersignekees
to installa above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire pla a system in operation until a Certificate of om liabce has been issued by the Board of Health.
Signed /' + Date !7 l�
Inspections /C/Z _511 K ."
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COMMONWEALT14 Of MASS-ACHUS ETT"
b3 Board ofHeLrlth. � -1V%Oy, MA. 3• �� fw A0
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!CERTIFICATE OF COMPLIANCE
Description of Work:. U Individual Component(s) WComplete System
The undersigned hereby certify that the Sewa e Disposal System; Constructed ( ),Repaired ( ), Upgraded O/,Abandoned ( }
by �iajQas4dC s�
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has been installed in accordance with the •ovisio of 310-CMR 15.00 (Title 5) and e pproved design plans/as-built plans relatin to
application No. "r ate proved Design Flow ( d) 9£�i ,t
Installer �, SC Cpvkv l► 1+"
Designer: V 111 is (� �+:} Inspector: ' Date
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. _60 T�7-D ' R_D' iK) r ' L )M , FEE . 005 '
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL. SYSTEM CONSTRUCTION. PERMIT
Permission is herebyranted to; Constre Re Upgrade (VAbandon an individual stem a disposal s
g u _ air( ) Repair( ( ) g P Y
at /Y 0611,4k7_0 I OL /AI as described inthe application for
Disposal System Construction Permit No. ' ated
Provided: Construction shall be completed within`th o the date of this peri it. All local conditions must be met.
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Form 1255 Rev: 5/96 A.M. Sulkin Co. Chadeslown, MA Date. �� Bo rd of Health
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