HomeMy WebLinkAboutApp-Permit-ComplianceNo. P7011—DC49—C
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FEE
COtMMONWFALTII OF MASSACHUSETTS _ :;` ���� =rlp►G
Board rfHealth, Yr crnOVYi7 ,AM.city' 1.�019 1 C
APPLICATION FO -11 DISPOSAL SYSTEM CONSTRUCTION ' ERNIT .-,1 rFpT
Application for a Permit to Construct( ) Rcpaq t) Upgrade( ) Abandon( )-_�omplete System ❑ Individual Components
Location /C)
wncr's Namc
Map/Parcel# 7
Address
Lottlk a
Telephone# W,7 Ub 3a ra
Installer's Name !-•a
(i bn Designer's Name &OMS& 614
AddressAddress
Ced
Telephone# S0KTelephone#
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Type of Building klleslGlmil z d Lot Size /81 - (; sq. ft.
Dwelling - No. of Bedrooms !e/r/• Garbage grinder M?
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures t�
Design Flow (min. rcgti red) �7 U gpd Calculated design flow yyU Design flow provided t' L J 7
. YSgpd
Plan: Date o� Number of sheets 1 Revision Date i
Title p
Description of Soil(s) 6l" �ee. /662 S o� Ci rr ^ �{aj t "rdn d
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OFREPAIR.SORAITERATIONS 4'_AShC //
G r of C. or l.` r n n Ln it f
The undersigned agrees to install the above described IndiJidual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of 5ornBance has been issued by die Board of Health.
Signed -_— Date h
Inspections
No. h l 4 f'.^°." 8f"8 C °"w t"4'y,r1; ,�v�. FEL' � , �t
CO MONW LTII OI; MASSACIIUS-LTTS ,
6- , rt1l
Board of Health, 49A4FWj0TM. Mfl. t,,V c.(kf 064 %
CIERTIFICA OF COMPLIANCE
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Description of Work: ❑ Individual Component(s) [complete System �p`
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired(t(..), Upgraded (� /Abandoncd ( )
by: J" to • V � i2m• iz, 1. i'x Kl i)
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. leaf,. r -✓r' , dated di'.,. Approved Design Flow </4/1 (gpd)
Installer _.. 1j 17. )t,.�
Designer: m. }' Inspector. d` .r`� . �N. ,.� , Date:
The issuance tof this permit shall not be construed as a guarantee
tete that tlryfe sayyst,em will function as designed.
No. °�' " .. - 6� c '"'"I ,� T1s re .0 ,.,$ e.,..ra�.ai� . ., •i 1"�a tr .� o�_' d
COI ON A1.TII OF MASSACHUSETTS
Board ofHealtly MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FCC
Permission is hereby granted to; Construct( ) Repair Upgrade ())"l Abandon ( ) an individual sewage disposal system
f
at fl ? LZ C4 rlr ( -f-"e, 7 as described in the application for
Disposal System Construction Permit No. _f �w 1 , dated
Provided: Construction shall be completed within three years of the date of this,.permSt. All local conditions must be met.
J
Form 1255Ner. 5196 A.M. Sulkln Co. Ctoreslan, MA Date `/ rw':e d° Boarcl of Health