HomeMy WebLinkAboutApp-Permit-ComplianceNo.O W -4 /'.'.0
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W-COMMONWEALTIIOr MASSACHUSETTS
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
v Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑
FEE j6KS.L
CA43963
0FC 17 2019
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
No. of persons
Lot Size Z I sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) '�'2 7 U gpd Calculated design flow 3 3 G Design flow provided gpd
Plan: Date 1. 6 - \ % - � c( Number of sheets ' - Revision Date
Tide F -`i\ 9- 13j`.i.. "
Description of Soils) _
Soil Evaluator Form No
.V
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS et C- G
of Evaluation
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 place a system in operation until a Certificate of Compliance has been issued by the Board of Health.
/ Z
Signed Date
V"
'ggi�'gg.
26FEE
COMMONWEALTH OF MASSACHUSETTS i"I #',
Board of Health, *#1110 d t1- MA. "y -
CERTIFICATE OF COMPLIANCE
Description of Work: ❑'Individual Component(s) ❑ Complete System ,�-
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (V, Upgraded (\; Abandonedat ( )
a
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
application No.
,..t'M"r*`°''" dated %-e,.?"Approved Design Flow '"'!_.. (gpd)
Installer" -
-
Designer: Inspector: Date:
The issuance of [his permit shall not be construed as a guarantee that the system will function as designed. "
No. V;101; 0 C - i u'(..w. 7Z FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT 1
Permission is hereby granted to; Construct( ) Repair( ) Upgrade f Abandon( ) an individual sewage disposal system
n
at t;43k t;4as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit; All local - conditions must be met.
Form 1255 Rev. 5/96 P.M. SAM Co. ChadeAam,MA Date f � "'`f' . ? is Board of Health C . �+ � l t -- ,"li, .;it -- 1 ies•�'
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Tt<i �ju,kLocation
Map/Parcel# Wt a P 1 to
Address — Z
'CW\
Lot#
Telephone# _7GG 731\
Installer's Name Jo✓tzl,,
C?xCe,J e,�'tC��
Designer's Name
(/1/((�k eC_
Address 1 e>
eo, d (-sQ eC�
Address p
Telephone# 50 o- J�-$ 8-7-J6z)U
Telephon
.3 C -C, 3
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
No. of persons
Lot Size Z I sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) '�'2 7 U gpd Calculated design flow 3 3 G Design flow provided gpd
Plan: Date 1. 6 - \ % - � c( Number of sheets ' - Revision Date
Tide F -`i\ 9- 13j`.i.. "
Description of Soils) _
Soil Evaluator Form No
.V
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS et C- G
of Evaluation
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 place a system in operation until a Certificate of Compliance has been issued by the Board of Health.
/ Z
Signed Date
V"
'ggi�'gg.
26FEE
COMMONWEALTH OF MASSACHUSETTS i"I #',
Board of Health, *#1110 d t1- MA. "y -
CERTIFICATE OF COMPLIANCE
Description of Work: ❑'Individual Component(s) ❑ Complete System ,�-
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (V, Upgraded (\; Abandonedat ( )
a
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
application No.
,..t'M"r*`°''" dated %-e,.?"Approved Design Flow '"'!_.. (gpd)
Installer" -
-
Designer: Inspector: Date:
The issuance of [his permit shall not be construed as a guarantee that the system will function as designed. "
No. V;101; 0 C - i u'(..w. 7Z FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT 1
Permission is hereby granted to; Construct( ) Repair( ) Upgrade f Abandon( ) an individual sewage disposal system
n
at t;43k t;4as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit; All local - conditions must be met.
Form 1255 Rev. 5/96 P.M. SAM Co. ChadeAam,MA Date f � "'`f' . ? is Board of Health C . �+ � l t -- ,"li, .;it -- 1 ies•�'
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