HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSACHUSETTS
Boa>:d offlealth, YQv'VAy-J F-�` , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMI1
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Atplication for a Permit to Construct( Repair.( UpgradeC>Y_AbandonO SKComplete System 0 Individual Components
ocation 4 (! " � �i `.k RG
Owner's Name fck Vk 0i -Q_ Q�l�
ap/Parcel# —70 _7,
Address / Co h10 etr.klk R -A 5 7CkrUtC-4j
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Telephone# -7 tj - _7 ZZ --1 j, 3(3
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taller's Name ��
Id
Designer'sNamedressAddress
1 Z v C c v s f `[� Far
Telephone# -q3q
Telephone# ,c"Q' F—l' 7.7
Type of Building ��2 S �( c�Q ti+ic,
Lot Size 10tcly� "meq. ft.
Dwelling - No. of Bedrooms Garbage grinder {
Other - Type of Building ^,I' 112�r No. of persons Showers ( ) , Cafeteria {
Other Fixtures 4-1
Design Flow (min. required)"�h _ gpd Calculated design flow - �3 Design flow providedPd
Plan: Date Ce k \ 6 Number of sheets Z Revision Date
Title
Description of Soil (s) U _5 / /-1 t_t 5 7 /Z f'jh GTg vv►V Jw h a 7 Z; -?5 N _" - I `(7 C �7
Soil Evaluator Form No. Name of.Soil EvaluaLor sI" l y Date of Evaluation 411911
8-q,/ me 54�:7 —LS"y2
DESCRIPTION OF REPAIRS OR ALTERATIONS 126J 5-O glv� 42 �<,-i•_. ( , J-=
A--E—W Com., i=.,r r /� u{ e- 1• -RJ -) W / A t s C? I I S i1L , t
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 -and
further agrees toot to place the system in operado er icate H
of Compliance has been issued by the Board of Health.
Signed 4 Date flw&a(c)� 201 cl
Inspections
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No. FE
COMMONWEALTH OF MASS�L]L7CLJ �(ie ^�j�( �i� IK( dl �
Board of Health, �+ ����G' i -1'' MA. t'U 1
CERTIFICATE OF COMPLIANCE -1,q
Description of Work: 0 Individual Component(s), AComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ); Repaired ( ) Upgraded'(bandoned ( )'
by:
at, lG Ur 6'4 4 Ut l 5 C s �ll 'Co -A C\-,\-
has
i,\has been installed in accordance with the provisions of 31,Q CMR 15.00 (Title 5) and the opproved design plans/as-built plans relating to
d �
application No. date ' ' Approved Design Flow-(g'Pd)
Installer �l;�Lr -.'ir '�cTti_.f)C�1��N itilC
Designer: �\ f ( il= t�tr- ft-) Ins ectou' " %v
g� (`'- o�� P _� ' J .�'' .. Date;
The issuance of this permit shall not be construed as a guaran ee tlfat tiie y�tein` f1 1-14ron as design"
No. _-► G -J } n FEE
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COMMONWEALTH OF MASSACHUSETTS -70
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Board of Health., 'ec, � " o j .l"_� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Y, Repair( ) Upgradek\) Abandon( ) an individual sewage disposal system
at 4 ( H,!� Lt 6 ,34 VV i`t as described in. the application for
Disposal' System Construction Permit No. - 9 "i dated
Provided: 'Construction shall be -
l
com eted withia11Ae '�
p, es„s of:C�ie date of this :per mit. All local conditions must be met..
Form 1255 Rev. 5196 A.M. Sulkin Go. Chadeslown, MA Date. of Health