HomeMy WebLinkAboutApp-Permit-ComplianceOMMONWFALTH Of MASSACHUSETTS
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Board of Health, , AP"1OlTM , Mfl•
APPLICATION FOP DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
® plication for a Permit to Construct( ) Repail grade( ) Abandon( ❑ Complete System ❑ Individual Components
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Name
Map/Parcel#
Address
Lot#
Telephone# (0 ZZ "-7 o D
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Installer's Name04
Dir-nesigner's Name N
Address 6 ,� Y "A �
Address �G t. +'
Telephone# . 77(�
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Type of Building — lk1
Dwelling - No. of Bedrooms
Other - Type of Building _
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No. of persons
Lot Size 0 g & 0 sq. ft.
IF
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. requ.red) _ gpd Calculated design flow ,tom S% Design flow provided gpd
Plan: Date 7 Number of sheets / Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Tit S1a /_/* 4'C :4, �� � d • &I,1,,._ / i'�1 Sed c hn.-kz S' 16e-- SAS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Co pli ce has been issued by the Board of Health.
Signed 0� Date ��
C®MMONW LT14 ®E MASSACHUSETTS
Board of Health, YAfZMOIfC'�E , MA.L "� %'�/�j
CERTIFICATE OF COMPLIANCEjUg
Description of Work: ❑ Individual Components) Complete Systeme The undersigned hereby certify that the Sewage Disposal System; Constructed /(7 ), Rte-p`aired (/)rade ( andoned () `
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has been installed in accordance with the provisions ofj10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated _` l.. Approved Design Flow (gpd)
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Installer IT Kf _
Designer: St.el.•e r""' Insp;::�d(di`e�sys(tem
Date:
The issuance of this permit shall not be construed as a will function as designed.
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COMMQNWEALTH Of MASSACHUSETTS
Board of Health, YA rOAO U rr�
DISPOSALSYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair' ) Upgrade( ) Abandon( ) an individual sewage disposal system
at J6 / as described in the application for
Disposal System Construction Permit N(il , dated C `fit
Provided: Construction shall be completed within three s o th'e date of this permit.; All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulk'n Co. Chadeslown. MA Dat oard�oof Health