HomeMy WebLinkAboutApp-Permit-ComplianceNo. ♦ �.�-`�- �,C, FEE X55, Oa
1&0W -0C -1q--05_'75 COMMONWEALTH OF MASSACHUSETTS C.Oc�O�lsb
( e oard c f Pleallh, MA. � c!
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION P['du*0:bhiF04cD0PT
9 2099
Application for a Permit to Construct( ) Repair() Upgrade( ) Abandon( ) - ❑ Complete System O Ind
Location
Owner's Name
Map/Parcel# t_'
AddressgoGd
x� �,-(?, `� �tl Cl
Lot# (1C.(
Telephone#
Installer's Name (~�5--�'"
Designer's Name
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Address '3 !'Vq
Address
Telephone# t� - L
Telephone#
� u —
Type of Building Lot Size 5,(50(, sq. ft.
Dwelling -No. of Bedrooms -3 Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. re aired) � l CU � gpd Calculated design flow J � Design flow provided C) gpd
Plan: Date t) 6 M C% Number of sheets 3 Revision Date
Title
Description of Soil(s) (
Soil Evaluator Form No.
.rJS'—111thAA'i ��AI:X C i-ocVLculJ
Name of Soil
of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to re /�ey/�ht operation until a Certificate of Compliance has been issued by the Board of health.
Signed / / / Date
No tt' "d 'i t 9
• t"` `„,t 1 1 I" ° FEE s�v 'r„y"'a
COM[MIONWEALT14 OF MASSACHUSETTS p g
Board of lealth, k`�"d"'r. ¢�"7 / t22-' , M l• I 1
CERTII~ICATl E OF COMPLIANCE
Description of Work: ❑ Individual Component(s) El Complete System le \
The undersigned hereby certify that thepp.,Sewage Disposal Syystem;�5Constructed ( ), Repaired ( ), Upgraded'm(. , Abandoned ( )
by: k r 7p1 r
at Q C.„v Y�.w �, i-- r &_A
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ikx) .., :.:I ra dated UA I d 19 Approved Design Flow " "tet"": (gpd) r.
Installer
;^
p s
Designee 9" '`ti `% is l t `P+'N" e')(' Inspector:.3t�s . .v°�r .•�rdi`�`":ka•.�er�M'.�.*.. Date: 4°716
The issuance of this permit shall riot be construed as a guarantee that the system will function as designed.
No. h) i� 4`( `- C.+i od f �C.. '.�. 1, l,. * ... FEE 4ttJl (D )
r d b C9M[MIIONWEALTHOEMASSACHUSETTS
Tor rf Health, i'Board /-M ,,1J*�det� MA.
> I l' x
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Up rade"(Q Abandon( ) an individual sewage disposal system
at 5_g $:;"lair.(.,' c""?e r as described in the application for
p y t.� <,
Disposal System Construction Permit No. 'a esxa,$,C ,dated a
s (
Provided: Construction shall be completed within three years of the date of this, erupt. All local conditions nujst be met.
Form 1255 Rev. 5196 N.M. Sulkin Co. ChaleslaVn, MA Date .,441 hw$ Board of Health
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