HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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COMMONWEALTH EALTH Or MASSACHUSETTS RIECEWED
Board (f Health, w1aMA. OC
% 3 2010
APP11CATION FOR DISPOSAL SYSTEM CONSTUCTIDNIT
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Application for a Permit to Construct( Repair( Upgrade Abandon( ) - ❑Complete System Q] idividual Components
Location l rRt°WlW
Owner's Name ✓�
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Map/Parcel#
Address 5n- U31 tit
Lot#
Telephone#
Installer's Name
Designer's Name
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AddressW,r✓F M�
Address U,-tMI
Teh:phone#
Telephone# ltd - 'tori
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Type of Building I/(/'i t t'(t-^' Lotsize sq. ft.
Dwelling - No. of Bedrooms Garbage grinder's
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. equui
Plan: Date ' Ie.. 2,C
Title Cllr Y'
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets I
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow
Revision Date
of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furl er-agreed ' not to pia tile system mu
erahon"'intil a Certificate of Compliance has been issued by die Board of Health.
Signed s��`.w i C.x.-.;,��� Date 1,%r :� d._
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Inspections y\
t- �R f„t`a en r r-,
No (°'"')�-:'(.�-�i •,�... bI- - FCL
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COMMONWEALTH OF MASSACHUSETTS f. __,..,..
t7+�3 ' Ceov'� +""' 9 �"•`v3 • M
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Board ofHealth,
CERTIFICATE OF COI�PLIANCE ' A
Description of Work: Q Individual Component(s) ❑ Complete System
The undgrsigned hereby certify that the Sewage Disposal Systegt; Constructed ( ), Repaired ( ), Upgraded.(.,), Abandoned ( )
by. m(�9191Lw4[
at dP`_'
has been installed in accordance with the pr visions of 310 CMR 15.00 (Title 5) and
application No 6r 0 dated -I L9 . Approved Design Flow
Ins[aller C.. -i (,.',`(, t14r"i�...
Designer: huspectoic I���t`•-.-att(ii- r'.
The issuance of this permit. shall not be construed as a guarantee that the stem will•.
approved design plans/as-built plans relating to
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.mow.,.•., Date.•
Ion as designed. {
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No. �t )- "• FI'C
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COMMONWEALTH Of MASSACHUSETTS
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Board of Healthy 1 if 11 7 (t_l t ,t) w`� MA.
DISPOSAL SYSTFM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade(,) Abandon( ) an individual sewage disposal system
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at 'Z, )) v°t`, 1, i}�'F,a. 01�:.� J `' C).�.�h tiY,�l.)( �r as described in the application for
Disposal System Construction Permit No. _:7 . t)r; ., dated 1• e%
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Provided: Construction shall be completed within three ,years of the date of this permit. All local conditions must be met.
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Form1255 Rev. 5/96 A.M.SulkinGo. Chaoe evkh% Date Board of Health '~,. 6