HomeMy WebLinkAboutApp-Permit-ComplianceNo.bo{RDc4q-6 66D 6LZT F_ - U -M 1 X12.1
1 ' a,act COMMONWEALTH OF MASSACHUSETTS
Board affleallh, Amot rf-u 'Am.
APPLICATION FOR DISPOSAL SYSTEM: CONSTRUCTION
Application for a Permit to Construct( ) Repairk) Upgrade( ) Abandon( ) - ❑ Complete System O
FEE G. W'
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SEP 12 2019
IIT
HEALTH DEPT
Location
3 D Nv)/v 5 -�WC oz4LLe"-
Owner's Name
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Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name ,S' 6'4W11A1V &C t/AYIIV
Desig"ner'sName
Dmj le.V-"/U
Address
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Address
Telephone#
(+3e- ),sb 5 -
Type of Building __,7 aU . Lot Size�' o — sq. ft.
Dwelling -No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ,3�i D gpd Calculated design flow Design flow provided 31%yD• el, gpc
Plan: Date Number of sheets / Revision Date IV Z6
Title 5 aj f7[f l oyc- Mo igas o� c owy-rA c7e oy
Description of Soil(s) .S N
Soil Evaluator Form No. Name of Soil Evaluator 13 PNAJdrhl Date of Evaluation Z
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DESCRIPTION OF REPAIRS OR ALTERATIONS 7) -bo 7C 4 _"_S /)A4' 1Lp..)____:�25ry
The undeQ1-gn-eq agrees to install a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ag&es [o of to pla to tet n operation until a Certificate of C%�plian a has been issued by the Board of Health.
Signed t r Date
Inspections
No.1AX) 1 i
COMMONWEALTH OF MASSACHUSETTS
Board of lea/th, Vr d'Fi )Li MA. �) F
CERTIFICATE OF COMPLIANCE t
Description of Work: ❑ Individual Component(s) ❑ Complete System re
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( `,Abandoned ( )
at ;;y '-e ,�)t'' L. r cV
has been installed in accotdlnce with the prow. tons of 310 CMR 15.00 (Tide 5) and the yaproved design plans/as-built plans relating to
ted ,iz°} / c ;5'_tt•.
application Nto, das .! e .Approved Design Flow � (gpd)
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-U1}'r,i) t .rPe`" 0.t¢ 3t""`A0 Inspector: L! '3l%'y'q ee,a°°``.+ ,,.1.°:�.�.a.� Date:
Designer: t p c
The issuance of this permit shall not be construedas a -guarantee that function as designed.
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No. 9 t1yFEE "A0
COMMONWEALTH OF MASSACHUSETTS
BoardnfHenitlt,)}€�^4
DISPOSAL SYSTEM CONSTRUCTION PERMIT °
Permission is hereby granted to; Construct( ) Repair( ) Upgrade) Abandon ( ) an individual sewage disposal system
at ^^ `1 i,°' f �'' as described in the application for
Disposal System Construction Pe`nnit No. 19` dZc�l , dated 9 O° )
P
Provided: Construction shall be completed within three years of the date of� this permit All local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Ctale5I NNMA Date /e, 9 t,° i�fBoard of Health
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