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HomeMy WebLinkAboutApp-Permit-ComplianceBoard of Health, liqAM 0l01 , MA. FEE iss-, or) c6k,w9 APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repaii•*Upgrade( ) Abandon( ❑ Complete System 01,dividual Components Locations ,���� -- Owner's Name Map/Parcel# ZZ72 Address Lot# Telephone# Installer's Name �47� J- Designer's Name Address ��CV ��// j 71VT1,0 C Address Telephone# S a94f7WyZy Telephone# Type of Building Aon G, Lot Size sq. ft. Dwelling - No. of Bedrooms 7/ Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator r., DESCRIPTION EPAIRS OR ALTERATIONS 1'6' L - Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree top a the s em in o eration a Certificate of Compli ►ce hasbeen issued by the Board of Health. Sign Date ��.(. Inspections No.���'I���V �" /,ox FEE tot COMMONWEALTH OF SSACH T �T�� � y Board ofHealth, yUMfi 4 �_, MA. CERTIFICATE ©F COMP]LIANCE saq• /te Description of Work: Individual Component(s) ❑ Complete System Ae� b The undersigned here Yertify that the �Sewa a Disposal System; Constructed r L..Re aird�'�.UPgraded Abandoned by: () at " has been installe iEi�} ZI?Xd �c application No. `" Installer ae M AVm ,in Pie'pio,Wons of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated ---� -- Approved Design Flow (gpd) Designer: Inspector: The issuance of this permit shall not be construed as as guars Date: 5 � that the system will function as designed. No. F20 1 (o -I 0:E:60 ACC U c1 6?C+fSZFEE s s , b 16 - �� CONl[MONW ]LTH ®F MASSACHUSETTS e.k.,-w b W9 Board of HeeaTlth, �r�"M o.LM, MA. g�, g DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair) Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No.}, dated C`,�'' i Provided: Construction shall be com ete wtt iin tlaxee o �re�date of this ermit.I All local conditions must be met Form 1255 Rev.. 5/96 A.M. Sulkin Co. Chedeslown, MA Date 1 .S / Boa a of Health r l%