HomeMy WebLinkAboutApp-Permit-ComplianceNo. DOW -UC -1G-10-735
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, 7A -Ad i.AL4. I MAY "i 9 2016
PPLICATION FOR, DISPOSAL SYSTEM CONS RUCTIO�]_� PER '!THaLT�T.
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Application for a Permit to Construct( ) Repair( pgrade( ) Abandon - ❑ Complete System >a Individual Components
Location 1,- C
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Owner's Name L r
Map/Parcel#aS
Address
Lot# I G5
Telephone#
Installer's Name Capt
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Designer's Name
Address �! 0.
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Address
Telephone#sof Zq0 VOID ll( 7ZZ 't-011
Telephone#
Type of Building h p
Dwelling - No. of Bedrooms _,p
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
gpd Calculated design flow
Number of sheets
Lot Size
No. of persons
sq. ft.
_ Garbage grinder( }
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
I OF REPAIRS OR ALTERATIONS
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The undersigne ees to instal4abo rib=untila
ewage Disposal System in accordance with the provisions of TITLE 5 and
further agree ace thratioficate of Com lia}ice has been issued by the Board of Health.
Signed ate'l 16
Inspections
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No. (.-1073,54— FEE
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COMMONWEALTH OF MASSACIIU$ ETTS���
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Beard ofHealth, til � e = ' ,. MA.
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j CERTIFICATE Of COMPLIANCE
Description of Work: C041dividual Component(s) Q Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired � , Upgraded ( ), Abandoned ( )
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has been installed i accordance
application No.
Installer 1`1,0-( cesk j(ac,
with the provisro s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated t / Cp- —. Approved Design Flow (gpd)
Designer: Inspector: Date: G �a
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. E�U-br - 1 G "(0 7 3 � (. -k "Y E {' c % f% i � C.. 11\)'m t • FEE
COMMONWTALTH Of MASSACHUSETTS
Board of Health, V f/— M b 1 , MA. —D - G
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair(/) Upgrade( ) Abandon( ) an individual sewage disposal system
at t �' t v E as described in the application for
Disposal System Construction Permit No. - i , dated `,7 /°
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. 5/95 A.M. Sulkin Co. Chadesfown, MA Date �, � i Board of Health
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