HomeMy WebLinkAboutApp-Permit-ComplianceFEES V `�
COMMONWEALTH Of MASSACHUSETTS
Board of Health, y , MA.
A T ICATI®N UnD MS®CAT SYSTIUM[ d-®NSTDUCTI®N DEDMIT
Application for a Permit to Construct( ) Repairq) Upgrade Q/) Abandon() - ❑ Complete System Individual Components
Location „99j /
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Owner's Name / �/
hC1L•-1�?4�•�/
Map/Parcel#
Address
Lot# 40-
Telephone#
Installer's Name r
Designer's Name ��,�,��
Address
Address
Telephone#
Telephone#
Type of Building �k�Ale Lot Size %7, ���i& -`- sq. ft.
Dwelling - No. of Bedrooms 13 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) -1�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
DESCRIPTION OF REPAIRS OR ALTERATIONS S::!ne-/^
Date of Evaluation
The undersign ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to to c e tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date R" le 4
Inspections
110-
7101 COMMON LTH Of MIASSAC14USETTS
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FEE CIA 5 (
PCS -%715"
Board of Health, y8R1Molm , MA. � , 010
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The.undersiFed-her eby c rtify that the Sewage Disposal System; Constructed ( ), Repaired (Y), Upgraded (ij, Abandoned ( )
at
has been installed in accordance with thepro�7sions of 3 0 CMR 15.00 (Title 5) an the approved design plans/as-built plans relating to
application No. r ` �, dated '� ._ icY ^� Approved Design Flow (gpd)
Installer o ,. .,--T f LA g. (f' c C-.
Designer: 71` %1 A rTAQ S Inspector: t Date:
The issuance of this permit shall not:be construed as a guaraniellltbat the system will function as deigned.
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No. FEE
�0 "C -{o-62-°` COMMONWEALTH OF MASSACHUSETTS
Board of Health, TA R—k0U7N , MA.
DISPOSAL SYSTFM[ CONSTRUCTION PERMIT
j.
Permission is {her�eby granted to; Construct( j Reair( ) Upgrade (Y) Abandon( ) an individual sewage disposalisystem
at 2, Sl/G'�C,r�f/�"dy%l% as described in the application for
Disposal System Construction Permit No. iU , dated
Provided: Construction shall be completed within t lO
p 1��..f-s of thedate of thisr "t:�All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslowh, MA Date Board of Health