HomeMy WebLinkAboutApp-Permit-Compliance (WITHDRAWN)No: OW DC -l9 -3W ( 440 bl&011 FEY, 53. ®o
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COMMONWEALTH OF MASSACHUSETTS
Burd of Health, 1atMOLA-4!) ,AVIA.
PPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Pei -mit to Consrruct() Repair(k Upgrade( ) Abandon( ) - ❑Complete System O Individual Components: 06 /13to
Location 3y So u Tk JifA. Ave—
Owner's Name ,1 -►SLK
Map/Parcel# 60-Z, tQ
Address 3 so uAA 5'e.,-, AV e_ 1J. VxirA1w
Lot#
Telephone# 7/6----\537- 2, 3 ZI-
Installer's Name -XII L.
Designer's Nam
Address 'Zy 6r faAWe,6+e-rr, 0. 0GPG%1a /44a
Address
Telephone# 150g _Sp g- 11-059
TelephorleN
v
Type of Building Lot Size sq. ft.
Dwelling -No. of Bedrooms Garbage grinder ( )
Other - Type of Building X, No. of persons Showers ( ), Cafeteria. ( }
Other Fixtures
Design Flow (min. required) gpd Calculated���Rcvision
Design flow provided gpd
Plan:` Date Number of sheets Date
Title
Description of Soil(s).
Soil Evaluator Form No.Name f Soil Evaliia r Date of Evaluation
DESCRIPTION OF REPAIRS OR.ALTERATIO S ,MC14,A 111 ,u v\ e 07 l
n`G .'Fwy1.r, l yl).
The undersigned agrees to install the above escribed Individual Sewage;Disposal System in accordance with the provisions of TITLE 51 and;
farther agrees to nplace the system in op
ot t ation until a Certificate of Compliance has been issued by the Board of Health.
Signed (0,e - Date
Inspections
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No.FEE
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COMMONWEALTH OFSSACHUj.\TTS c oq�as
Board of Health, �( � i�.
CERTIFICATE Of COMPI
Description of Work: jXTndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Construct (
by iV�el'P' , t9LAr LB,J-- rC'
at S t1e_.,
4
Upgraded ( ) ,lAnd!
has been installed in accor a e with the provisions of 310 :CMR :15.0 (', �) and the approved design plans/as-built plans relating to
application No. g' dated e n Flow {gpd)
Installer T , 19L .TY -16.
Designer: �"_" _ Ins cc r- V Date: _
The issuance of this permit shall not be construed a tee that the system. will function, as designed.
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No., 66 14 X-49-3401 FEE VV 1 60
0 ON LTH Of MASSACHUSETTS 70L
Board f Health, O U %� , MA..
\ P SAS. SYSTEM CONSTRUCTION PERMIT
Permission is hereby gran teto ; onstruct( ) Repair(V Upgrade( ) Abandon( ) an individual sewage disposal system
at 1 e�t�V Ji _ as described in the application. for
Disposal System Construction Permit No. �L; dated ._
Provided: Construction shall be completed within three years of the, date of this permit.,,All local condition; must be met.
Form 1255 Rev. 5/96 A.M.Sulkln Go. Chadegown, MA Date V //� Board of Health Z ��