HomeMy WebLinkAboutApp-Permit-ComplianceNo. to a c - LbT2 ' 1 `1 DU 59 1 j
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/ OMMONW LTH Of MASSACHUSETTS
/ ,.`� Board of Health,/YI Di , 1VlA.6j�
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FEE "`i v
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plication for a Permit to Construct( Repair(-) Upgrade4..rAbandon( ❑ Complete System e9dividualComponents
Locatioci: t15P.QGh�16V1 Owner's Name Q YU5 UI
Map/Parcel#1 labAddress3100Glr I %tr10
Lot# Telephone# t)v& .3(z .o0q
nstaller's Name l_.l'lGt 1 e_(-(hatJ- Designer'sName 1 t Afv-% fo vl
Address3o "`y%t fit UX 6 Address Q le -A IV ay,_4(1 Mt14J
Telephone# Telephone# `�� c-�- .
Type of Building ' Lot Size sq. ft.
Dwelling -No. of Bedrooms o Garbage grinder
Other -Type of Building, No. of persons. Showers ( ), Cafeteria
Other Fi:ettu:es
Design Flow (min: required) gpd Calculated design flow -3 Design flow provided 330 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 agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and;
further agre to not to lace th :system' peration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
4G
No. 13Ql{�C"IC(—Gsa'tR� FEE
COMMONWEALTH OF MASSACHUSETTS ly5y;JF
Board
of Health,
6b
CERTIFICATE OF COMPLIANCE
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Description of Work: Q<,dividual Component(:) ❑ Complete System !✓ G 1 %
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ), Upgraded L(_j Abandoned O 7
�l
by: 1 y', ;11 t° t lirl-
at (1 0Yii0 ( t .a h(j1� rk11't uta (AY A'1() It VAI
has been installed cordance with therovisiotas of 310 CMR 15.00 (Title 5) and pp
approved design plans/as-built plans relating to
application No.
dated11171— ' / 51 .Approved Design Flow---�`-(gpd)
Installer <P
Designer: r' -r P b� , iLt Yr`t t l,n i7rs1 Inspector: Date:
The issuance of thistpermit shall not b�trued as a arantee that the system�will function as designed,_ : _
No., bCVN-Dc -1q-nq-7 �,C�t�i�� 4� ���t-� _ ` � FEE ' S ,00
5Y
COMMONWEALTH OF, MASSA � jTSETTS
Board of Health, YA{d O MA.
DISPOSAL SYSTEM CONSTRUCTION.. PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade�bandon ( ) an individual sewage disposal system `` \
at,,_ L 01 �p b ic, �V_YYi ) 6 alt% . as described in the application. for
Disposal System Construction Permit No 9�, dated 1�
Provided: Construction shall be completed withi��eS of thdate of this permit. All local conditions must be met:
X2 X
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Form 1255 Rev. 511 .M. Sulk n Go. ChOestown, MA Date r>� Board of Health -