HomeMy WebLinkAboutApp-Permit-ComplianceNo. /� l -a 1 T' ���5<-/
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FEE �l O (1
COMMONWEALTH Of MASSACHUSETTS
41C
Board of Health, �"�"��� , MA. ' hov�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair() Upgrade( Abandon( ) - ❑ Complete System Ar Individual Components
Location 60
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Owner's Name S vaee-}
Map/Parcel#
3 2 — 142 ,N
Address (o p l vn�-Qad' -Yq� k -E, 4- A
Lot#
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Telephone# 6 Z67
Installer's Name
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Designer's Name ✓
Address1
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Address C��
Telephone# .S6
S, 7 7 6
Telephone# �� g _ -� — 3) 6 2Vc Y4
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Type
Type of Building 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) gpd Calculated design flow?r' 3 d Design flow provided gpd
Plan: Date q L Z i L( Number of sheets Z Revision Date
Title19alg r s -ed �-e� +&- �y s �e�r. UQ2 Ca r�� P� 044 ( C' -r " �e.� �-r Yet cin �, a 0 A
Description of Soil (s) d -4A, L S, —2y 91 L5ot 24- 3Z Ci,' L5,1, Z-57 C`Z '. s .l y? -74C3 1~C Se nA
Soil Evaluator Form No. Name of Soil Evaluator 4y)k C ,c `Date of Evaluation T(.= 14 '� C (A
7Z,0\4
DESCRIPTION OF REPAIRS OR ALTERATIONS
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The under ign ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur er e s to a system in operation until a CJ*cat of Co pliant has been issued by the Board of Health.
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Inspections / / 5' 0`%'i /5/-4 /✓�rl� l/-- - /�! �6t1��Lf�
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, , M.9.
CERTIFICATE Of COMPLIANCE
FEE
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Description of Work: ldIndividual Component(s) ❑ Complete System
The undersigned hereby certify t at the Sewage Disposal System; Constructed ( ) , Repaired ( ) , Upgraded �f , Abandoned( )
by: �OY7 ""
at (60 l ol., ii
has been installed in ccord ce with the provisio f 3110 CMR 15.00 (Title 5) and th roved design plans/as-built plans relating to
application No. `4 ` P ,dated SI � Approved Design Flow and
Installer '' /I S CG 6<19AQ /1 �,
Designer: G -!L . / /
The issuance of
ffjthis permit
No.
Date:
shall not be construed as a guarantee that the system will function as designed.
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, Yclr' '�,j R4, , MA.
➢DISE®SAI. SYSTEM[ CONSTRUCTION PERMIT
FEE'
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (r Abandon ( ) an individual sewage disposal system
at(� /y AA as described in the application for
Disposal System Construction Permit No. / , d ted <-` 0?7 14-
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Provided: Construction shall be completed withiff-dTree , s o tfie date of this aermit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date /`-Aoard of Health �L