HomeMy WebLinkAboutApp-Permit-ComplianceNo. Jw ® Sj-Q' GG'1� Ll - ree
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COMMONWEALTH OF MASSACHUSETTS
Z1_ Board ofHealth, �A tzcno+:'i�1 ,NIA.
>�I�LIC�ITION rOI� DISPOSAL S1'STI-M CONSTRUCTION ICK MIT
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cation for < Permit to Construct( Repair Upgrade( O UpgradeAbandon- Complete System ❑Individual Components
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Owner's
Map/Parcel#
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Address
Lot#
91
Telephone# �
Installer's Name
PQM C-
Designer's Name
Address
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Address i k) "7
Telephone#
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Telephone#
Type of Building �'�''`7l "�'�-i c'\ ® D.I°"1 W 0�_-I (a 6, Lot Size ZC l 5 C7 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder (/J/10
Other -Type of Building No. of Dersons cR Showers (KCafeteria (y�
Other Fixtures
Design Plow (min. rc uirec1) 2-p gpd Cal�ulatecl design flow (Oesign flow provided C-�4'3, ab'LL gpd
Plan: Date \ Number
of sheets \ Revision Date �
Title DDs-LSpeF e Jt=�4>SU\'�re� �t kgG? I�SPt, �'\ lA� �E.i`rs
Description of Soils) ko S?f7(l
Soil Evaluator Form No. ~_ Nvne of Soil );valuator ti'KLi> Date of Evaluation (a I LQ l tl
CY
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned ees o " stal a ap veescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place s eh in operation until a Cerfificate of Compliance has been issued by the Board of Health.
Signed Date 1;" \Cwy,
-Inspections
No. a ffr.. ':`'t..'7J .. ',wa lr7. "�✓�f,`"� FCC
COMMONWEALTH OF MASSACHUSETTS d�t, /eV /
Board of Health, t r ..>_ 9t;. rc"\ MA. 1 %�
CERTIFICAiTE OF COMPLIANCI✓
Description of Work: 0 Individual Component(s) 1 � omplete System
The undersigned hereby certify th at the Sewage Di osal System; Constructed ( ), Repaired N? , Upgraded ( ), Abandoned ( )
e�
at
has been installed in
application No. (i
Installer - f
with the rovisio s of . 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated � 9 �✓ Approved Design Flow," 6', 77 (gpd)
Designer: at w'a'{ Inspector: r'''^--, .. ,*' t ."(,,(./ f rf Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEAL' -11 OF (MASSACHUSETTS
Board of Health, 1 f'' a` C> \ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission isherebygrantedto; Construct( ) Repair(,<f Upgrade(
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at ( ss vSt> 4 t e
Disposal System Construction Permit No. i / , dated 0-
" F " ,
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shall be
FEE
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Abandon( ) an individual sewage disposal