HomeMy WebLinkAboutApp-Permit-ComplianceNo. _
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COMIM ONWEALT14 Of MASS C14USETTS Z,57
Board of Health, `X idyl , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# /c/o _.
Address
Lot#
Telephone#
Installer's Nam
Designer's Name
Address
D
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description ofSoil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned es to ins a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr on t to pl a tem in operation until a Certificate of C mpliance has been issued by the Board of Health.
Signed 46-- Date
Inspections
No. (�C�F{' 3� "' 4 "?. A FEE QQ
COMIM ONWPAI,T14 Of MASSACHUSETTS
Board of al(g. m % t� r% MA.
CERTIFICATE Of COMP
Description of Work: ❑ Individual Com onent(s) 0 Complete System 0 sr► �.
P P P ys
The undersigned hereby certify that the Vwe Disposal System; Cuucted ( Repaired ( )> Upgraded ( ),Abandoned ( )
by: `"" y� tet"4Vq ,n '; ae-YA,* e" f LIZ.T
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. Ll 8� dated Approved Design Flow '--' (gpd)
Installer LL t ,
Designer: Inspector: Date: -7 1
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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COMMONWEALTH LTH ®f MASSACHUSETTS ck4(75 7
Board of Health,&—gyh -,km. D �
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct (t•. Repair( ) Upgrade( ) Abandon(
at
Disposal System Construction Permit No. dated
an individual sewage dispos�fl system
_ as described in the application for
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 A.M. Sulkin Co. Chadestown, MA Date t l Board of Health 6- V-A