HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60A+D C4 -33 0S FEE' $6,52,00.
COMMONWEALTH OF MASSACHUSETTS 0 t(,Oqcp
Boardof Health, WM0 U-nA 111A.
APPLICATION F®I, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon,( ) - ❑ Complete • System ❑ IndividualComponents
Location 5
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Owners Name r CW1QRb
Map/Parcel#
lq3 . ! (0
Address 167yew A).
Lot#'
Telepho ie#
Installer's Nam
0A
Designer's Name
Address
t-O'TU�.
Address
Telephone#
_. /02
Telephone#
Type .of Building Lot Size sq. ft.
Dwelling - No. ,of Bedrooms' Garbage grinder
Other - Type of Building No. of persons Showers O, Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets _ Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The: undersigned,agr es to the above described Individual Sewage:Disposal System in:accordance with the provisions. of TITLE 5 and
further afire ;njto ace a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 3 1
Inspections
No. j?, 0-+.e p 19 "3 30FEE S1
COMMONWEALTH OF MASSACHUSETTS Cj4 q
Board of Health, , YgeM6tfn+ , MA.
CERTIFICATE OF COMPLIANCE
Description of Work:: KJ44vidual Component(s) El Complete System.
The undersigned hereby certify atthe Sewage Disposal System; Constructed ( ),Repaired (,<,Upgraded ( ), Abandone
by:iQ' I��iir5f.
at
has been installed in accordance with the rov'sions offS10 CMR 15.00 (Title 5) and the:approved; design plans/as-built plans relating to.
ppm, dated _ C J . Approved Design Flow"'" (gpd)
a lication N
Installer �c ���j/�i. f c 1l C" ? f T �'
f
Designer: - ""r Inspector: Date:
The issuance of this permit shall not be construed as a gpa'rantee that the system will function as designed.
No. 13
0�gvC w-i9—tea'03 C\iz 1t3(�l• On,3s`r)z FEE'
,
�,q- a COMMONWEALT14 Of MASSACHUSETTS
Board of Health, YMMO TIt , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to.; Construct( ) Repair(Uf Upgrade( ) Abandon( ) anindividual sewage disposal system
at _5� Vt
er{ 0'C ). as described in the application for
Disposal System Construction Permit No. 6 I dated
Provided: Construction shall be completed within three years of the date of this r it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health
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