HomeMy WebLinkAboutApp-Permit-Compliance(J81 }�C—i�l' 6�oJ�3 �° ` K I T t E ree
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COMMONWEALT11 Of MASSACHUSETTS C 3-7G0
Board of Health, *M50714- ,MA. -
APPLICATION 1-011 DISPOSAL SYSTEM CONSTRUCTION PIRMITP 2 7 2019
Application for it Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System Q Indi duall(rtol$pphp6tKPT.
Location
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Owner's Name
Map/P:ucel#
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Address 5P1 .�7/� ,CJ�y ,�-�•.v
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Lot#-
Telephone# tv
Installer's Name
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Desigher'sName
Address
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Address
Telephone#
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Telephone#
Type of Building /'-�� /� �di v Lot Size sq. ft.
Dwelling - No. of Bedrooms a .-> Garbage grinder ( )
Otter -Type of Building No. of persons —Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow+� Design flow provided 2 F`;3 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTIO OF REPAII
Name of Soil Evaluator Date of Evaluation
The undersigned agrees nstall the above descaed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no acelbe sys r er 'o amtB a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. 4_ (J 1 e f (�.`.J COMMONWEALTH Lt$LTH '1-Yll.
®� MASSACHUSETTS ✓ vR � t� v' �� ����� 2 }
Board of HealthA14HO a, , MA. j -.r i-1,
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CERTIFICATE OF COMIAIANCE �A<
Description of Work: ❑ Individual Component(s) ❑ Complete System d y
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired;(<„.�• Upgraded ( ), Abandoned O f
by: '
at
has been installed in accordance with the pr vi. roils of �8 Oab IR 13:00 (Tide 5) and the approved design plans/as-built plans relating to
application No. dated datedApproved Design Flow ""”" (gpd)
Installer c •c ),n" :'vi'w•"e:"-.'id. .
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Designer: '"`"" Inspector: PI,,...�`, til A° 91.��I,- t' 7 Date:
The issuance of this`permit shall not be construed as a guaranteethat the system will function as designed.
No. 210...�`C +1 _6 _%'w>V,. p pI CI'C
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COMMONWEALTH Of MASSACHUSETTS
t hoard ofHealllt, Y,44640 dZIF fYUI. `{-
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DISPOSAL SYSTEM JTicl°JI 'CONSTRUCTION PERMIT -
Permission is herebygranted to; Construct( ) RepairC,') Upgrade( ) Abandon( ) an individual sewage disposal system
at .,,.rb e a r« t. -4
ly as described in the application for
Disposal System Construction Permit N ^ l > ,dated % l E
Provided: Construction shall be completed withinthreeyears of the date of this permit. All local conditions must be met.
d J
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChztlegarlMA Date l 1`7 Board of Health R'