HomeMy WebLinkAboutApp-Permit-ComplianceNn:....: FEE 50
"COMMONWEALTII OF MASSACHUSETTS
Board of Health, =,r.l : MA.
CATION I FOIA DISPOSXT' �� � i, ftM' rCTION PERMIT
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Application for a Permit ttruct( ) Repair(">o Upgrade( ) Abandon( ) - Complete System 0Individual Components
Location -,t�.j {
, , jL
Owner's Name � }'
Map/Parcellf
Address (L 'i,1Wca
c«rm, i'
Lot#
Telephone# 3D'*'
Installer's Name O .�,
Designer's Name
AddressO.,- �,.. �" '� 1.�.
Address �3
-�,, Ymaj
Telephone# Gag ,_ P" —
Telephonelf 60 SW — 3
— G,
Type of Building
Dwelling -No. of Bedrooms
Other -Type of Building
Other Fixtures
F,
Lot Size 9 ` 4 � sq. h.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min, required)Y l 11gpd Calculated design flow .3Z7 Design flow provided �✓- Ste' gpd
Plan: Date l i"� � 3 i /� 0;2 Number of sheets n), -r._ Revision Date
Tire
Description of Soil(s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS
Name
Name of Soil Evaluator
11
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not Ln. la the system in operation until a Cerdficateof Compt�t�anc 1i een issued by the Board of Health.
Signed �� —�-- Date f7� OcTi�
' - FEL
t 3 COMM�ONWEALRI, OF MASSACHUSETTS
No. �.
A
Board of Health, jc' maV.`L MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 'd Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired N, Upgraded ( L Abandoned ( )
by: 9wrl } 14,1' t .,
at �--, k�-L'✓ H°:. �i1A �.�ws M' rnJvv,ou,�'�.
e with the provisions o('310 CNIR 15.00 (Title 5) and thea .roved design plans/as-built plans relating to
has been installed in iccordat �application No 612 f J dated 42—,' Approved Design Flow `'`7 ^'� (gpd)
hhsrnller
Designer: ^{ .*'-i`"f :' ks° dJl` Inspector: ""f °l¢ -«e. ,...1 w tce"C ' Date: .m° i" Jt~t a..3
The issuance of this permit shall not be construed as a guarantee thata system will function as designed.
No.
COMMONWEALTH OF MASSACIIUSFUS
BoardofHeahh, \!C� n �� MA.
FEL P«.,�... -ixv,?
DISPOSAL SYSTEM CONSTR'UCTION PERMIT
Permission is hereby granted to; Cynstrttet( ) Repair(s4 Upgrade( ) Abandon( ) an,inclividual sewage disposal system
at ✓ 1' lJ V % lA m 3.1.. as described in the application for
Disposal System Construction Permit No. .� dated
G+ d`Ju1
Provided: Construction shall be completed within three-yeamnf the date of this permit, All local conditions nipt be met.
Form 1255 Rev. 5196 A.M. Sulkln Co. Boston, MA Date Board of Health
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