HomeMy WebLinkAboutApp-Permit-Compliance; 4 . ° booc-I8 �5 G Lbw - 8-0015 9 8 1 FEE 1 o.DO
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X19" MM ON EALTII OF MASSACHUSETTS c� -7Z2
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Board of Health, y�.l�'�.Eil%�` , MA.
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' APPLICATION/// FOR DISPOSAL SYSTEM[ CONSTRUCTIONPERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - omplete System O Individual Components
Location
Owner's Name Stl�-W04K W !!IT d —bAAA( 7
Map/Parcel#
1S' }
Address 2-3
(}#ALgy(i (Z'b Spo,,OW!jCt� 1'c.1�4t94
Lot# 41
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Telephone#
t)+ g -1K 6L
Installer's Name
7 Q -TJR C"!) S .
Designer's Name�� �A,k e " � i N C.Sr4 g
Address
Se4t,,`t-vt 444:��n C r i
Address ?n
-it>'x ZO iW�46\' `t`Zt2. AA -Ai
Telephone#
s p ts'f i� 5-3
Telephone#
C9 id< . y'9 4 .-7-5 /f77
Type of Building :V -e5 li,? -eI h� Tt K L" /mak i- Lot Size 7-1 i 6 (0 a sq. ft.
Dwelling - No. of Bedrooms 5 F� Garbage grinder( )
Other -Type of Building Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) - " gpd Calculated design flow 5 � Design flow provided gpd
1
Plan: Date q 12,,01'6 Number of sheets1( Revision Date N d � et..-
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Title Cl" r C; �(? )�G 2 - �l � d Y3 V-- `a� STI M
Description of Sod(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to Inst to above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to ' plac system in operation until a Certificate of Comp�Q'ance has been issued by the Board of Health.
Signed Date / C) U�
Inspections� /f S0d t a.""" r 5
No. ;:a ..."fir f-",``,, FEE`.{" x .a
COM MONWEALTII OF MASSACHUSETTS
Board of HvalEh, a t MA.
Description of Work:
The undersigned here
by
at:1
has been installed in ac
application No.
Installer l"•l.::i:;.
CERTIFICATE OF CO PLIANCE
D Individual Component(s) aiomplete System
by certify that the Sewage Disposal System; Constructed j j, Repaired ( ), Upgraded ( ), Abandoned ( }
with the provisions 9f,310 CMR 15.00 (Title 5) and therapproved design plans/as-built plans relating to
dated `` K Approved Design Flow `, E <f" (gpd)
Designer: +...° I.. - , ' " t C "{i i' t ;, i t „_a, Inspector: i '� " <<"w.. t Date: r
The issuance of this permit shall not be construed as a guarantee that the system will function as. designed.
No. iri t i 4' 7' ! , `{.i i,.� t,..t, "`: F*.: Pr' k FEE'
,r COM MONWFALTII OF MASSACHUSETTS,kp
Pp Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
,,.
Permission is hereby granted to; Construct(,' Repair( ) Upgrade( ) Abandon( )an individual sewage disposal system
r.
at ; (-) `� i t�wibt.. �:` i 4.�> t°� t'r:x)� as described in the application for
Disposal System Construction Permit No. / ,° , dated a "
Provided: Construction shall be completed within thme years of the date of this permit. All local conditions must be met.
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frorm 1¢56 Rev. 6196 A.M. SUIWn Go. Chateslown, MA Date f' .'F, ` B„Qard of,hiealih �,, _„,, ('V 14
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