HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,�.'y e Y LSI �~ �� J ( ZjoV �� FEE'iV"
COMMONWEALTH OF MASSACHUSETTS CwSpo
Board of llealth, i Ott MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( )'Repair( ) Upgrade(-rAbandon(j - C.TComplete System O Individual Components
Location i C) ,S co N6TiZ )Jce
Owner's Name
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Map/Parcel# � ]7
Address W
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Lot# t j
Telephone#
Installer's Name GJ rZ� C 4J n C.
Designer's, Name rs Rix-- A) y exz fj
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Address 6 80� / A �'i. )J, AA ���
Address
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h. , &� iS 6A•_G
Telephone# JGs'-
Telephone#'
3(,;4, q&44:K
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder {
Other - Type of Building No. of persons Showers O,'Cafeteria
nth Pr Fi)enirPs
Design Flow (min. required) f i gpd Calculated design flow
Plan Date Number of sheets _
Title
Description of Soils) ?
Soil Evaluator Form No.
Design flow provided gpd
Revision Date
Name of Soil Evaluator
].1
DESCRIPTION OF
1
FREPAIRS OR ALTERATIONS
R
I �w i1 w) l % P% .A A Ino
The undersigned agrees to ins all the above described Individual Sewage Disposal System in accordance with the provisions of Tr= 5 and
further agrees to not to pl a cyst operation until Certificate of Co pliance has been issued by the Board of Health.
Signed Date l
11 Inspections
FEE
COMMONWEALTH Of MASSACHUSETTS
Board o Health, -!V Mi t1 MA.
f �
_� {�pT{p''�TJFICAT�E Of COMPLIANCE
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Description of Work:; U Individual Component(s) @'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded�( ' Abandoned ( )
at (� t: Cit` 3 ci' n1.Ayr
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No. j`?- ' f dated
Approved Flow—?z!f 7
Installer h P-, T V7 . 0 6 1� . 10 c � 1,&
vYl s
Designer: DA:- ) {`-lV mit-.. (r-1+ -51 N r Inspector: Date:
The issuance of this permit shall not be .construed as a guarantee that the, system will function as designed.
No. to 4b C - C1 2_(n5 Z, Q �'�!L 1 C3 • C \,)k,- Cc • FEE > 7
:COMMONWEALTH Of MASSACHUSETTS
Board of Health,YAQ,&Q VT _4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) UpgradeX Abandon( } an individual sewage disposal system
at ! } A3 GQ_ A as described in. the application for
Disposal System Construction Permit No. I dated ' f
Provided: Construction shall be completed within tl=4 f tie date of this permit All local conditions must be met..
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesiown, MA Date (b / 1 Board of Healthx-