HomeMy WebLinkAboutApp-Permit-ComplianceNo. 16ok4Dc-19-12`75 FEE (0
19- a,90 COMMONWEALTII Of MASSACHUSETTS MUM Q,- W-00XI-77
Board efHealth, _ Q , AIA. ! '
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APPLICATION FOR Yup�,rndc(
OSA' SI'SHM CONSTRUCTION PERMIT
ucttii, .r 17U19
Application for a Permit to Constr( Repair ) Abandon( -omplete System I] Individual Co'lrrponents
Location C
Owner's Name
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Map/Parcel# 6-',y zv"
Address a�rvrm
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Lot#
Telephone# --
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Installer's Name \ p ' aG
Designer's Name
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Address qjE�, r
Address 5
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Telephone# -- - -
Telephone4k"'
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Type of Building Q.C': Z�C\fl 0\ Lot Size _,.Z_Z2 .sq. ft.
Dwelling - No. of Bedrooms `.D Garbage grinder ( )
Otter -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) :V gpd Calculated design flow
Plain Date 11'1D / P Number of sheets _ �—
Title yr / I,Y-�-, pe %Zq /--,—
Description ofSoil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR
Name of Soil Evaluator
Design flow provided 5�`= gpd
Revision Date
Date of Evaluation
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees
,to% place the system in operation until a Certificate of Com Hance has been issued by the Board of Health.
Signed/ t -' Date �% moi^
Ne rcl
COMMONWEALTH OF MASSACHUSETTS
7
Board of Health,_ �1 nkrg )-°s- . MA • � 6� "` �
CERTIFICATE OF COMPLIANCE ij �,����,�4�1
Description of Work: ❑ Individual Component(s) Cl Complete System �✓
The undersigned hereby certify that the,✓Sekge Disposal System Co suvued ( ), Repaired„f, `') Upgraded (�);�Aban doned ( )
by, sr ` ,„.-s,,.r`"3'�.�^"` r'`rn�"'. �,`•- r�sd�r",*
has been installed in accordance with the pro%.sio]7 of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No f � A-9, , dated r°P � n='•,'°Ar`9 . Approved Design Flow - •`°'"' (gpd)
Installer
Designer.s1:,. C"s ). �.r�s t?I O.f',C..�' __..Inspector! �w) '.-•..tYi tt t� ""�.1 Y1'" Date:
The issuance of this permit shall not be construed as a guarantee that the systemY sill function as designed.
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COMMONWEALTH OF MASSACHUSETTS
f Board ofHealth,
�/ f LL " MA.
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DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(/,) "'Upgrade (V)Abandon ( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. l , dated ° --;r, ray .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M.&ulkin Co. Culeston, MA Date D t"dR Board of Health ?.'C.•