HomeMy WebLinkAboutApp-Permit-ComplianceNo. //0"C- Zo-41`IO FEE 4651C0
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Board of Health, 0-1-e MA.
APPLICATION FOR DISIW SAL SYSTEM CONSTRUCTION
'PERNIi IT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( - l7 Complete System U Individual Components
Location 3V
254--
Owner's Name ( (t/(G
Map/Parcel# 114•10&
Address
Lot,#
Telephone#
Installer's Name Co Q Cd .SP
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t,(,— -( 05 eC���
,/�besigner's Name
Address , (J,
qW cC� 2G 7 7^
Address
Telephone1t503 Z.yV 2,?;'da
% 7 Z2- '7Z`%
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
M
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil (s) _
Soil Evaluator Form No
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder (0
No. of persons Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRSORALT�IjtAATIONS
gpd
The undersi e s to Inst. Elie abov . cr' d tvrdual Sewage Disposal System in accordance with the provisions of TITLE 5 mid
further a es oto L. a syst Aeration until a Certificate of Coam/pliant has been issued by the Board of Health.
Signed Date �Z-✓/'��
Inspections
No. �0 114t r _?<.",1--"i'J`�(-,7 `lt"�` " n FEE �''.1�4✓
COMMONWEALTH OF MASSACHUSETTS
c Board of Health, eve MA. Dbt��ao2o
CERTIFICATE Of COMPLIANCE ry `'zyJ
Description of Work: CI Individual Component(s) i l Complete System I" ll 4 A
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The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (v° Upgraded O, Abandoned ( )�
by; &^APr- F €�t5 S,417in1``
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 Pe_r.r1 1" , dated .+$y 10 Approved Design Flow (gpd)
Installer �l ` ' '� >i r�• _ .
Designer: ..."°,"' Inspectorr: Date:
The issuance of this permit shall not be construed as a guarantee thattAlui systemavill function as designed.
No•-')`P.11•l h)$' . .°^� 14.- (.,$7th"O'�.%..i t... E'^:fj �" d FEE t )
c ~ COMMONWEALTH OF MASSACHUSETTS
Permission is here
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Board of Health, W $ #140 d 9 l+" , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
)i, Construct( ) Repair (v Upgrade( ) Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No. e tri— fk " , dated
as described in the application for
Provided: Construction shall be completedvv'thin ithree years of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 AM. Sulkin Co. Chaftoe ,MA Date '"s .a+'.•`' Board of Health ln°"^, d`�"-- "'f"°( -•s"