HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.'
FEE�s�.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to Construct( ) Repair/Upgrade( )` Abandon( - ❑ Complete System ❑ Individual Components
Location S
gks#7hC W 1144
Owner's Name yLL C.,OU 4114e -ti
Map/Parcel#
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Address
Lot#
Z ,2- 7 6j�
Telephone# AINKW 356 5! L-1
Installer's Name
A r
Designer's Name
Address20
Address
Telephone#Telephone#
_
Type of Building :)I r
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)O gpd Calculated design flow � Design flow provided 3 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
0K.0
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 to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date </.2000
Inspections
Gv
No. �3 FEE SD
COMMONWFALT14 Of MASSACHUSETTS 4 P, 7
Board of Health, UAerna MA. ek /
CERTIFICATE Of COMPLIANCE K' �
Description of Work: <✓✓I Individual Component(s) ❑ Complete System e-r�91��
The undersigned hereby certify that the Sewage Disposal System; Constructed (✓Repaired ( ), Upgraded ( ), Abandoned ( )
by: o�:Ash
at
has been installed 11L ac(
application No.
with the provisions of 310 CMR 15.00 (Title 5) and heoved design plans/as-built plans relating to
dated 7` /'7100. Approved Design Flow '(gpd)
Installer
,¢ a.
Designer: �Inspector:Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed..
No..O -3 /.3 ✓ / FEE
COMMONWEALTH Of MASSACHUSETTS
?0`
Board of Health, .a e aaa L MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(/ Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
I If Disposal System Construction Permit No.- -373 , dated
Provided: Construction shall be completed within t ehr y�` ears o1= the date of this perm,; All local
iconditions
/mus
t e met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / 6Z Board of Health
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