HomeMy WebLinkAboutApp-Permit-ComplianceNo. _ ! ✓(Vl �-- ► "� ' C� �J ! I tO FEE S
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COMMONWEALTH OF MASSAC14USETTS
sXI Board of Health,��%1-�iOUTi� MA.
G APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
p lication for a Permit to Construct( ) Repair( ) Upgrade O AbandonO -
❑ Complete System 0 Individual Components
ocation
Owner's Name
Map/Parcel# Al % rl;.-z ®r
Address
Lot#
Telephone#
Installer's Name
Designer's Name.
Address1-90
Address / f'la 4. /
Telephone# '� OZ%l
Telephone# � ae
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) 3,5 gpd Calculated design flow 330 Design flow provided 3 S gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil (s) 100
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS _�'/G✓
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a to not to place the system mi ope on until a Certificate of Complice has been issued by the Board of Health.
Signed Date
Inspections
No. + FEE
HtSfT
Board of Health, VA PEW 0 011
MA.)
C�a-G,
Description of Work: ndividual Component(s) ❑ Complete System �x
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired), Upgraded.- (F ).y Abandoned ( )
G Vv
Dy:
at
has been installed in accordance with the provisions of slo cG oo (Title 5) and the approved design plans/as-built plans relating to
application No�.e i c ' dated . :j—((-1 Ap roved Design Flow, (gpd)
Installer .nsPdl'-^'i_A A
Designer: r}r. z G. "__..1 Inspector: % Date:
'J � �
The issuance of tl/s permit shall not be construed as a guarantlet tha the system,will function as designed.
No. —i L'�y
Col�" WEALTH OF MASSACHUSETTS
Board of Health,.- Ykg m n (n, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(
at
Disposal System Construction Permit No.
;dated`
FEE
Ct #f Y
n( ) an individual sewage disposal system
as described in the application for
Provided: Construction shall be completed within three years of the date of"thi�erml Ait. All local conditions must be met.
Form 1255Rev. 5/96 A.M.SulkinCo. Chadeslown,MA Date �)' �'l Board of Health R, V� L
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