HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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66
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town of i�u�"Aeui k
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair OO Upgrade ( ) Abandon ( ) - ❑ Complete System tg Individual Components
Locmiar Owner's Name
�(a ����• �_l9OD
MaplParccl 11 _ 560-362-�8y0 Address
Lor H Teleplamo k
Roberi- a, t9ur C,o. Tnc
Install c sName Dcsigncr Nati
z� 3 b�hi his per[, . f ot,i�
Address Address
Ise) g-5n9-VOS6 ;301 S.44;71,
Telephone H Telephone N
Type of Building:
Dwelling — No. of Bedrooms
Other—Type of Building No, of persons
Other fixtures
Lot Size Sq. feet
Garbage Grinder ( )
Showers ( ), Cafeteria
Design Flow (min. required) gpd Calculated design flow gpd Design flow provided gpd
Plan: Date Number of sheets Revision Date
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation &
DESCRIPTION OF REPAIRS OR ALTERATIONSP1ar N/r/bl�inl'n� NbM BvdSt'de o -C-
ern �f��rt -!n inle_-N of 4 0-n'e I2.n,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed za& /7VWA 40be 4- a a"r- 69 Z'ie Date 7-19—L-7 f' :..
T..�n,...r..,.,e 2 •' 2. Z r
M
lffq e S e H Ki. Sf,//L I »z r-• I —('e t' I-iP �,l'rl-i n'-pT
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
_ _ ___ __ __ _ ______ ___ __ _ _.__
No. .i ` 22. OqH'� COMMONWEALTH OF MASSACHUSETTS G�(� Fre
Y�UA BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE (L-, Q -
Description of Work: j< Individual Component(s) ❑ Complete System uS� ( "-C ✓-i
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (X, Upgraded ( ), Abandoned ( )
by: 9Wj9ty,rd^ 9, &GY CO 7-r1 G
at /to t'G o le_ L_aop
has been installed in accordance with the Lrovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No ` �rS b- dated �' /7 Approved Design Flow (gpd)
Installer
Designer: Inspector P7 T v" \ Date 6 �
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM S/96
2-'
f ( C,
�" T E C MMONWEALTH OF MASSACHUSETTS �a
No. �" �T�i "� ' G �.,� f Fee _.Vi"""a
;t�M'.A100Tk BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair (.) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at /f„ JaRm /._e^ h as described
in the application for Disposal System Construction Permit No. % dated 2_
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Date C/ " d,a„_ Board of Health�l.' •� (* ,�^ ---�m-
FORM 2tl-DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) I -1&W HoessB WRRREN'm PUBLISHERS - BOSTON �,