HomeMy WebLinkAboutApp-Permit-ComplianceNo. F/� (� [„ k� �� ^ 20 .- fir o� �(o � FEE'
J - 76 COMMONWEALTH Of MASSACHUSETTS J41--iD q
Board of Health, 10JY V'11aAAAn 1G1A.
- PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( )'Repair( ) Upgrade( ) Abandon( - D Complete • System 0 Individual Components
Location c—l `�/�i ov''� �
Owner's Name
Map/Parcel# J �� f
Address
Lot# (Z
Tele hone# �
Installer's Name�; �o,�e tJ prw�
Designer's Name
Address!b �p�,�� t'i!'l �,,t%it•�
Address
Telephone# Ste' - -
Type of BuildingR6,41 t/- /`- c' f �/ Lot Size sq. ft
Dwelling -No. of Bedrooms Il Garbage grinder.
Other -Type of Building No. of persons Showers ( ), Cafeteria (
Other Fixtures
Design Flow (min. required)
Plan: Date 3 -;Al G
Title
7 etl0 gpd Calculated design flow Y y� Design'flo,
Z Number of sheets _ �' Revision Date
Description of Soil(s)'.
Soil Evaluator Form No. Name. of Soil Evaluator Date of Evaluation
DESCRIPTIONO PAIRS ORAI TERAT NS 1"` e� 1 �� �v�` v '� 64,--,4%
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The undersigned agrees to install thSabo3o0escrjibendividual Sewage Disposal System in accordance with the provisions. of TITLE 51 and;
further agrees to not to lace ax-lyitem ra a Certificate of Compliance has been issued by the Board of Health.
Signed Date l J
Inspections 8LXOP C(c $o`(
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No. 6Q4 V- 6'"6`1 2-,�> ..�'�""._. FEE 00
COMNION�1LT41 Of MASSACHUSET S.�°�
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Board of Health,; A -.0
94\500-M , MA. 900109 9I y/
CERTIFICATE OF COMPLIANCE (9.)" ice- U v`� � ►9
Description of Work: ❑Individual Component(s) ❑Complete System.
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The unde�si ned hereby certify. that the Sewage Disposal System• Constructed ('Repaired ( ), upgraded), Abandoned ( ).
at
has been installed j ccordce with the pt rtg�'sioli of 310 CMR 15.00 (Title 5) and t e approved design plans/as-built plans relating to
application + dated 3 t p % Approv d Design Flow f (gpd)
,Installer a.. G�-'.a •- .a .,�, i./e,.',,-
Design
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Designer: [ Inspector: 15Lp.!V!1 Date: f 5c' l 1-7
The issuance of this permit shall not be construed as a guarantee that the system wilt function as designed.
No. bo 6Tc^{"'(r"i i��3a� ti v FEE'
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COMMONWEALTH Of MASS,AC14USETTS
Board of Health, ,NIA.
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DISPOSAL A CONSTRUCTION PERMIT
Permission is hereby granted to-, Construct( ) Repair( ) UpgradeAbandon( ) an individual sewage disposal system
at - t//Gr t as described in the application for
Disposal System Construction Permit No. jdated s (t (l .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date a u`"� Board o£ Health
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