HomeMy WebLinkAboutApp-Permit-ComplianceNo. B0-DC—I�'—� �i7i FEE S�DU
N,r,e,o ��c cam( (` rrr la COMMONTFA TII OF MASSACHUSETTS e(L13
19'a57;�� Board of He allle, �(�GI� NTA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct.( ) Repairm Upgrade( ) Abandon( - ❑ Complete System Cl Htdividual Components
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LocationP
Owner's Name -Tct.n b QWSdn
Map/Parcel# 01M,731,
Address II&ABy69 6&eA 9eedF W k-1,toKA, Ms}
Lot#
If
Telephone.#
Installer's Name jo{
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6q (tu ck4t
llesighcr's Name
Address17. PdIA dke
D/'irt 5.
DeoAb M# g4roo
Address
Telephone# sog - 776e -3cl 7,7Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of slicers
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder (�
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
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The undersigned agrees to install d above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees(te�1To'f't p nee ill sem in tion lint a Certificate of Complian/qee has been issued by die Board of Health.
Signed ` �+ Date �1;W 2- 7� /
Inspections /D � l® d �� ® g
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Board ofI-tl�eaallt{h,`pT\/lt�`:✓plot "dT��(¶q �T NIAl4} r (Yt r)
CERTIFICATE OF COMPL11�NCi
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Description of Work: ElIndividual Component(s) ❑ Complete System
The undersigned`hercby certify that Ute Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded ( ),Abandoned( )
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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
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application No. dated 9 . Approved Design Flow (gpd)
Installer �1 e r;
Designer: `"` Inspector: t �°:..�,�"a''�"`„t7"..-�"a°�'�+ro^"' Date:
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The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. aE_i t'3 ._e. g' dl>< <.: t' CJ ,.> �.a (--l' (':A.fv�v Zl,....
COMMONWEALTH Of MASSACHUSETTS
Board ofHealth, ,a,_b&ft9f) MA.
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DISPOSAL SYSTI-KCONSTRUCTION PERMIT
Permission s hereby granted to; Construct( ) Repair�(,Y") Upgrade( ) Abandon ( ) an individual sewage disposal system
at/e =$.11 Rt` 'f as described in the application for
Disposal System Construction Permit No. ZL e.0a- 5 , dated def," ';?6i .
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Provided: Construction shall be completed with/in three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 6/96 A.M. Sulkin Co. Chatlestaq MA Date ,r t�` 6lr Boardof Health,_,,"ta`F�r"�.�es