HomeMy WebLinkAboutApp-Permit-ComplianceNo. o -S-19
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COMMONWEAaq,OF MASSACHUSETTS
HEALTH DEPT.
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Board of Health, 11, G ,.;_ �� 1� w- � , MA.
APPLICATION fOR DISPO. V��tWMAWCTION PERMIT
Application for a Perm, igkf nstr' (, ;P r( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location -; /� , ��
Owner's Name ✓ C (�e„2 G' j,l �J
Map/Parcel#3
Address
Lot#
Telephone#
Installer's Name & d l
Designer's Name
Address ,r
Address
Telephone# d
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
* Plan: Date
Title
Description of Soil (s) _
r Soil Evaluator Form No.
r2 3
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
_ Date of Evaluation _
n(Q a- Rt �
gpd
The unders' ed agrees to m tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e s to"no to a operation until a Certificate of Cr plice has been issued by the Board of Health.
7Signed Date
Inspections
No.
1<GMMONWEALTH OF MASSACHUStTT'
Board of Health, �JL-1) MA.
CERTIFICY E Of COMPLIANCE
Description of Work: ❑.6dividual Component(s) ❑ Fompete System
The undersigned hereby certify that the Sage -Di �posal Systpyu instructed ( ), Repaired ( ), U
by:
at 7� 2 rn ., _ C. t l; i i
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A
4d ( ), Abandoned (�.
has been installed in accordance with the pro of 310 CMR 15.0 (Title 5) and the approved de4gn"�lans/as-built plans relating to
application No. C) i U7 dated p% 03 Approved Design Flow dgp�)
Installer �r— _l r L i ,:_ i\ 1 -. Fv i
Designer: Y Inspector:l ! `' �) `� l) -Date:
The issuance of this permit shall not be construed as a,gfa�A&e�at the syst xi.'rvill function as designed.
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No. FEE
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COMMONWUALT14 OF
CHVSETTS
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Board of Health,
DISPOSAL, SYSTO(CONSTRUCTION PERMIT
Permission is h�reby granted to; Construct( ) "Repair( ,_) Upgrade ( ) Abandon ( ) an individual sewage di� osal system`'`, '
at `n as described in the application for
V
Disposal System. Construction Permit NoD dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Farm 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health