HomeMy WebLinkAboutApp-Permit-ComplianceNo. P n 4V C• -1 q-238 ( FEE'
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COMMONWEALTHOF MASSACHUSETTS
Board of1lealth, �(4r•w►-es U4-ki , MA. l' K y�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( -) .Upgrade ()�-Abandon( ) ❑ Complete System ZQndividual Components
Location 1-7 1
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Owner's Name r'Li cke�e �rr:S
Map/Parcel#
B G -19(1
Address 1 ? Wp_'.r YCat
Lot# 1 CN
Telephone# '-7 -7'-j - N 7-7 Z 39
Installer's Nameh
Designer's Name �y� : U---, inti
Address �
,
y T
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Address �2 Wo�cosS`�a`cl 1'Lc°t �s`giA-d1�.a
Telephone# •
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Telephone# 5-0 4? -7 -S 3 r3
Type of Building P.e s� � � S `'�Zj\e_ � "� 7 Lot Size i q Z 'VA sq. ft.,
Dwelling - No. of Bedrooms '4' Garbage grinder
Other - Type of Building Air No. of persons Showers( ), Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 4_16ra Design flow provided- gpd
Plan: Date Number of sheets Revision Date
Title cd 19.P C �j s crti ,moo- e.n �P `e ,-, l -7 l �C �, �Cst qlY► �c,.i( e� �—
Description ofSoil (s) 4- r7- L 1 Z- -3 Z L..S 32- 1 3 7- C
Soil Evaluator Form No. Name of,Soil Evaluator ��-� ('��4 late of Evaluation iQ hr,
DESCRIPTION OF REPAIRS OR ALTERATIONS
21 1, C'.' 1-4 - Za Ig �_ I 'D i-ffyc-e Le c -,
The unde -i agree o' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e on p e the system in operation until a Certificate of C mp 'auce has been issued by the Board of Health.
Signed Date
Inspec
COQ] MONWEALT14 Of MASSACHUSETTS
Board of Health, cl g"vh 0'-j MA.
CERTIFICATE Of COMPLIANCE
Description of Works j Individual Component(s) ❑ Complete System 07Z
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgrade Abandoned(
by: -)s "i '; 01"_'.1
at
has been installed in ccPr&jnce with the provisions op1.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. >! , dated;4Approved Design Flow '4 gpd)
Installer
Designer: ZF `� Inspector,, % % 9� Date: -
The issuance of ' permit all not be construed as a guafantee that the system will function as designed.
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, tea: r%,AauMA.
DISPOSAL SYSTEM CONSTRUCTION'- PER IT
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FEE
Permission is herebygranted to; Construct( ) Repair( ) Upgrad5�;k/) Abandon( ) an individual, sewage disposal system
at t W 'g r 12°" t as described in the application for
Disposal System Construction Permit No..��""- rte' ,dated
c
Provided: Construction shall be completed within , of fR date of this permit. All local condidg.jrs must be met.
Form 1255 Rev. 5/9fi A.M.;Sulkin Co. ChaBestown, MA Date .% ` - 02rd Of Health � t... i..� .%fC..w•c�