HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE I � - 00
k ?AW A G SCOMMONWEALTH OF MASSAC14USETTS c*.,* tq 6
10mhoard of Health, y6,9:MQQ-n4 MA. I �
APPLICATION FOR DISPOSAL SYSTEM 0 01n, cp CONSTRUCTION PERMIT 31
Application for a Permit to Construct( ) Repair( ) Upgrade/Abandon LJ Complete System"In vidual Components
Location
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Owner's Name Tq
jMap/Parcel#
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Address
Lot#
Telephone#
Installer's Name
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Designer's Name 8 7s's
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Address
Address
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Telephone#
Telephone# -C c, S. -_z$ E: -S 3 L/
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size sq. ft.
. Garbage grinder
No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date I Numbir of sheets Revision Date
Title Zv iV /9 -f- Z/pw/-
Description of Soil(s) _
Soil Evaluator Form No. Name of Soil Evaluator-7'ohf 9 71 r- ZA114 A o
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DESCRIPTION OF REPAIRS OR ALTERATIONS go�l�� -/-
of Evaluation E, —/
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The undersigned agr5peto install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees tot ?�h in
V � �atia , ertcate of Comp, " e has been issued by the Board of Health.
Signed
No. E
COMMON WEALT14 OF MASSACHUSETTS 71-1-7,16 ck*1583
Board of Health, yhoiqvni MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ./ Individual Component(s) L] Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired Upgraded Abandoned
by: (i S CC, Z
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has been install
application No.
Installer j-
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wiwithge provisions of 310 CMR 15.00 (Title 5) and the ,approved design plans/as-built plans relating to
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dated Approved Design Flow 74 7 (gpd)
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Designer: S C 47 r ),V- i- 1:':),( i4 prtt Date:6 6-1k
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, )LA91!�00TIR—, AL4.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
permission is hereby granted to; Construct( ) Repair( Upgrade �Abandon( an individual sewage disposal system
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a�� L4 1 v 0 V e- escn4d in the application for
Disposal System Construction Permit No. /b dated,,'f-.2-P -14
Provi&d: Construction shall be compie2 dwithin-tbxAo-yeei4of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board ofHealth' Zazz"z,