HomeMy WebLinkAboutApp-Permit-ComplianceNo. Dv Sl L—1 I—v✓37 FEE
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-2,0L/ COMM OF MASSACHUSETTS c,rf3aw�
Board rfFlealtie, Y a rlltNAA- 1 MA.
APPLICATION FOR DIS
OSAL SYSTEMCONSTRUCTION P EMIT
2,
pp cation for a Permit to Consn'uctO Repair( UpgradeAbandon O - ❑Complete System Individual Components
ao
L.r cation
Owner's Name
M p/Parcel)k
Address
Lot#
Telephone#
Installer's Name
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Desigher's Name
Address 7'_0,
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Address
Telephone#�j`f/� 'L` CJ ZjtY�
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Telephone#
Type of Building Y
Dwelling - No. of Bedrooms,
Other -Type of Building_
Other Fixtures
Design Flow (ruin. required)
Plain Date
Title
Description of Soil(s) _
Soil Evaluator Form No
DESCRIPTIQN OF REPAIRS
&c, -led 1'4
G
_gpd Calculated design flow
Number of sheets
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Name of Soil Evaluator / Date of Evaluation _
11 PSc'a/� �P4G�iLt`7 �'�'c0��- yart
The unders' n . ees t stalldescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a + s o ce m in operation until a Certificate of Comp�janc as been issued by the Board of Health.
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Signed i ! Date o
No. FEE „.
<< w� COMMONWEALT14 OF MI ASSACHUSKTTS $`��
Board ojldeallla, 6 2ct ) F i:lj F r —
1'n
CSI1 IFICATE OF COMP.LLANCE
Description of Work: Individual Component(s) ❑ Complete System ✓`
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (k, Upgraded ( ), Abandoned
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicatiou No ti t') )(j dated ,, C-40 Approved Design Flow - (gpd)
Installer ;c>.4 e )"n
Designer:- Inspector: �yr'?t'rE'yo... ."y Date:
Y 1 a
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. —6 � FEC
COMMONWEALTH OF MASSACHUSETTS O 'l
Board ofHeallla, MA.
DISPOSAL SYSTEM CONSTRUCTION PI ER IIT
Permission is hereby granted to; Construct( ) Repair(t"') Upgrade( ) Abandon( ) an individual sewage disposal system
e:)ha?1(
at as described in the application for
l . 4 •
Disposal System Construction Permit No. "E '` ` Lt+ , dated f, / k
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M.9ulkIn Co. Wotan, MA Date 1 C Y k €°r' Board of Health , �' , k r ..t`1 d`•�2,