HomeMy WebLinkAboutApp-Permit-ComplianceNo. _&Qnc- tq-4`CV to
DEIVED
FG
COMMONWEALTH Of MASSACHUSETTS
DEC' �J2�JAP
Board ofHealth,
Y�uuou MA. A. `
LICfATION FO -11 DISPOSAL SYS LYI CONSTRUCTION PERMITHEALTH DE
Application for a Permit to Construct( ) Repair( ) Upgrade(-0/Abandon( Complete System O lndividualComponents
Location 7.
6
Owner's Name S,
,c` - �.
Map/Parcel#
Address 7 c
` 5 'j"K�
Lot#
Telephone# C_( "'_
3 2 C .. <'3 73
Installer's Name �,�
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Designer's Name,M,.,,..
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Add ress,�.�J
a
Addresses
Telephone# c'S ",�-60 ct
Telephone# e"Q
-• ��
Type of Building ,` `-� Lot Size I H, % c4 sq. ft.
Dwelling - No. ofBedrooms'
.?1 Carbagegrinder
Other -Type of Building No. of persons Showers O, Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided ?��/,^%gpd
Plan: Date \\ I ) f Number of sheets _ Revision Date
Title
Description ofSoil(s) �7 �. �:✓�
Soil Evaluator Form No. Name of Soil Evaluator. '(�,,R., .N Date of Evaluation
D+ESCRIPTffIaaON OF//REPAIRS ORAITERATIONS a .�. ,� l l ��CS� �,.e �lGri✓a � ! 4`.t � r
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 place die syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed -"'�_ Date
Inspections
No 1f7t' \1€°. ...I,<_@t.,::7 p FCL
COMMONWEALTH OI+ M ASSACHUSETS , . X1 1 C
Board o(Health, YA)j2 4W n O p- tVIA. 32PI CERTIFICATE'OF COMPLIANCE 1
oDescription of Work: D Individual Component7s)k "0,&mplete System
The undersigned hereby. certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,r), Abandoned ( )
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- dated Approved Design Flow t. -a. (gpd)
Inst111cn
Designer. r`,h .r r.r-m "-j Inspector: F ?.!. %w �`' t r- �?.-:', Date: "`:`l��r`:✓t
V a.... v, r �?
The issuance of this permit shall not be construed as a guarantee that thesystent will function as designed.
No d ,„:-.y �c-'�-i140(e- FEC
tl E `t COM ONWE ALTA Of MASSACHUSETTS
Board of Health, VARTho TI -d, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (u,)'" Abandon( ) an individual sewage.disposal system
at _ 1 t as described in the application for
Disposal System Construction Permit No.
ja) oJ3 ,dated
J
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5195 A.M. Sulkln Co. Chun eoen,MA Date 1,5'.117112 Board of Health
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