HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSACHUSETTS
Board of Health,)Mga oi- , MA.
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
. Ap lication for a Permit to Construct( ). Repair } Upgrade( ) Abandon( - ❑ Complete System ndividuai Components
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Location
V
Owner's Name
Map/Parcel#
Address
Lot#
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Telephone# f o"I" 7
Installer's NaunKL;e
Designer's Name
Address t-1
Address
Telephone# 5-D
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Telephone# 301e,-,77-5 Z
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. ofersons Showers( O, Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description ofSbil(s)
Design flow provided gpd
Revision Date
Soil Evaluator Form No. Name of Soil Evaluator 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 agrees of to pl system ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. &44 ,D C -- -6 1 o l,A 4�1 f FEE
A6-16-9 COMMONWEALT14 OF MASSACHU 61`�/ 6*1 Ck* (o -7 2—
Board of Health, _ 49M A i , MA.
CERTIFICATE Of COMPLIANCE
Description of Work; Individual Component(s) ❑ Complete System
The undersigned herecertif that the Sewage g y ^ y ge Disposal System; Coni rutted ( ) , Raired , Upgraded ( ) , Abandoned ( }
by:
at
has been installed in accordance with the provisions of 910 CMR 15.00 (Title 5) and�hWapproved design plans/as-built plans relating to
application No. , dated 7 Approved Design Flow (gpd)
Installer --Ta f - 1M,—\ 2--n rJ _
.Designer: Inspector: � Date: � Z&
The issuance of thispermit shall not be construed as a gu tee that the system will function as designed.
No.�1�—Ula ACV`-f vt� FEE.
/JO COMMONWEALTH OF MASSACHUSETTS 671 Z,
Board of Health, _Vd4 O M4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(» /Upgrade ( ) Abandon( ) an individual sewage disposal system
at—,2-3j� �.0 c- tip? e CA. C= Vim) , �' as described in the application for
Disposal System Construction Permit No. �r--1' dated
Provided: Construction shall be completed within the w,-wA of the date of this permit. All local conditions must be met.
_ leo L✓w S L,
Form 1255' Rev. 5/96 A.M. Sulkin Co. Chadegown, MA Date ��Board of Health ' .
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