HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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CO NWEALTII OF MASS(CI-IIJSET cam'
Board of Health, jbliJl OMI -174 ,MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
t:yJplication for a Permit to Construct( ) Repair( ) Upgrade( bandonO - e<o_mplete System ❑ Individual Components
.ocation V 9 e& ' RD
Owncr's Name h 1 C -'e4'
ap/Parcel# '!* ig 7Address
7 2
ot# 4/ 9
Telephone# 5Cs� S 57 S ss
Installer's Name Z—ov V, ccrt'
Designer's Name
Address 3O - C 1
Address f-
cLAA[3 /C
Telephone# " ('j '3
Telephone# c 6
Type of Building !0 (Ate, Lot Size
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers( )�, Cja-ff et�eria ( )
Other Fixtures -/ S Yom....
Design Flow (min. required) gpd Calculated design flow yqa Design flow provided
Plan: Date 2. 1 Number of sheets 1 Revision Date
Tide
Description of SOH(S) _
Soil Evaluator Form No
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRSORALTERATIONS n ClX) S LASl"/ C s�/Sd-CNy
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, i`Le undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre s �9/j1tot to place the system in operation until a Certificate of Comm lip ance has been issued by the Board of health.
Signed / N/ _ " Date 7 /c�S//(-II�.1,_
yyy _ tE A/.n„l• / wp" t� to/ee/l9
No `
COMMONWEALTH 4LTH OF MASSAC11US
Board ofHealth, j p ! MA
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CERTIFICATE OF COMPLIANCE,?, ,gs _ _ U/ oop3115
Description of Work: ❑ Individual Component(s) U,Cbmplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded tt( .),, Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built. plans relating to
application No "�`� "� � �' � ,dated °`� � `�" /` �"`�. Approved Design Flows» r- � (gpd)
Installer 1 ` t}l`*i " x( �I�C'+l) n"° x`''.,�"✓s�'�.wPr",t`�
Designer: hnspectot r"ti Date. 12
The (issuance of this permit shall not be construed as a guarantee that
thatthe system will function as designed.
No. �
FFE I -
COMMONWEALTH
OF MASSACHUSETTS "l
Board of Health, y n-,?Ftr4d€.)"i' -f - MA.
I
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade-
Pj Abandon( )an individual sewage disposal system
at t"& ciw,"`�. r�x.� T"� (�:,� d as described in the application for
Disposal System Construction Permit No. / fix' dated e-7•
Provided: Construction shall be completed within three q a�s of the date of this permit. All local conditions must be met.
Form t¢asRev, aissAN, sweinCo. cFadesavn,tu Dater ':t'' �``i' Board ofHealth "'r`
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