HomeMy WebLinkAboutApp-Permit-ComplianceNo. (1 d (CfL� C/ �!r 1 / v��L�i f ' ,�'� % l G t/�%� �/ �lLd1�iGF E.6�a k-4qe bl,-" V.- COMMONWEALTH OF MASSACHUSETTS
ICU 76Board o Health, "`(A� �` S Rttrf F= 28 MA.
APPLICATION FOP, DISPOSAP;Y9TFWMMVft-'TION PE MIT
Application for a Permit to Construct( ) Repair( ) Upgrad4')-"Abandon() ❑ Complete Systemndividual Components
Location `,
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Owner's Name p h vZ l�o C /
Map/Parcel#
f C43 ASO
AddressC cr+-► 4l
Lot#
Telephone# C,02
Installer's Name l „S il� f C0 4 -q
Designer's Name�%,yt jGf /�� G �� f' lu
Address3
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Address �G� -4K df'O
Telephone#6
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Telephone# 5'2c e
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) r
Plan: Date 4.pr i) 7 , das
Title
gpd Calculated design flow
Number of sheets
Design flow provided
Revision Date
Description of Soil(s) L'S
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
gpd
The undersigned agrepg to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to ace muntil a Certificate of Compliance has been issued by the Board of Health.
e Signed r Date
Inspections
No.
IC,
COMMONWEALTH. Off' MASSACHUSETTS ok -7
Board of Health, +%r < •) "t 7 MA.
CERTIFICATE OF COMPLIANCE Ida
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed { ), Repaired ( ), Upgraded ( ), Abandoned O
by:
at
has been installed 4l accgr� e with the provisi ns ofj 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /��%// dated /0~ Approved Design Flow ""' (gpd)
Installer j i i 0(; d c) r f, �C "1
Designer: l%tic: -} L' C-7 � I `J C, S 41 eC4: Date:
The issuance of this permit shall not be construed as a guar ee th the system will function as designed,
No. VCS l e / lj i` G FEE J eCf .
COMMO-NWEALT14 OF MASSACHUSETTS
Board of Health, . i4 / ar. T-11 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to, Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at a 1-C
as described in the application for;
7 . >2'! Caw! ,'✓`�. '. +��
1V
s f,:
Disposal System Construction Permit No. ✓„ r �`,dated y -
Provided: Construction shah be completed within t-Uc v� f he date of this pe it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ~�� Board of Health C