HomeMy WebLinkAboutApp-Permit-ComplianceNo.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y 47 ? x'1.0 0 -1-N N MA.
-APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair (A
Upgrade( ) Abandon( ) - 0 Complete System
FEE 5 )
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25A��
MAY 2 0 2019
HEALTH DEPT,
Location 10-3 AOwner'sN
Cr-�AKe.s �F{�16� €.
Map/Parcel# �q
6ame
Address 7
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Lot#
Telephone#
Installer's Name �
Designer's Name M 1A
Address /�3
Address
Telephone#7.0:9
Telephone#
Type of Building 6 A "T Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder.( )
Other - Tvpe of Building No. of persons Showers ( ) ,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 Soil (s)
Soil Evaluator Form No. Name of.Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ki-`d 0�:62)r- CV(774- 74— I� �.
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree rl,"n in operation until Certificate of Compliance has been issued by the Board of Health.
Signed Date _ Q01 C/
Inspections
No. � 3 c — �l -? � S7J o' %� r r �/, FEE ` f
���'l[I��N�ICT� �� N�S�.���US�TT�
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Board of Health, \169M 1 4 MA.
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CERTIFICATE Of COMPLIANCE
Description of Work:, � Individual Component(s) ❑ Complete System �E/r � It P�✓ '
The undersigned hereby certify that the Sewage Disposal System; Constructed O; Repaired 1 Upgraded( ), Abandoned ( }
by: L_�ItK I C -ft
at 4: 11
has been installed in accord ce with the pr-ovis)io�ns of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. f , dated Approved Design Flow (gpd)
Installer
Designer: �Inspector: X Date:
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
No: l" l"'t� �� C�i�;C?tUC�" FEE
/ . /4 COMMONWEALTH OF MASSACHUSETTS l h0E5
/
Board of Health, VAUMOUTM , MA..
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( ) Repair ) Upgrade( ) Abandon( ) an indiv dual sewage disposal system
at 63 .46i a+ ► JAS l 57O Lr-ld YAkiLt6Q _'4 as described in the application for
Disposal System Construction Permit No. ,� �' �f, dated
Provided: Construction shall be completed within � s of t�e date of this perinit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chaddown,MA Date d1 !`Board of Health