HomeMy WebLinkAboutApp-Permit-Compliancei No. IN h6t, f pIcr 0.;? FEE
COMMONWEALTH Of MASSACHUSETTS=�Oz�
Board of Health, OtCTY (} MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT i
Application for a Permit to Construct( ) Repair( ) Upgrade�andonO ❑ Complete System Q-15i5vidual Components
Location 7
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Name
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Map/Parcel#�
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Address
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Lot#
Telephone#
Installer's Name
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Designer's Name
Address
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Address 0
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Telephone#
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Telephone# t-
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Type of Building hot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( }, Cafeteria ( )
Other Fixtures yy��
Design Flow (min. required) L% V gpd Calculated design flow Design flow provided Z gpd
Plait: Date 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 Aeu) b &X * 11G,Kh 1-n `' l i elS
The undersigned agrees to inst the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t place e s tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
'No.f'>✓✓r'-,,�6/ _. 6 � FEE
_ � k ., COMMONWEALTH Of MASSAC USETTS
Board of Health, , MA.
CERTIFICi.ATE Of COMPLIANCE � � rye` ,
Description of Work; Q'Individual.Co' onent(s)` ..O Complete System
The undersignedfhereby certithat the Sewage Disposal System; (
Constructed ( ),`Repaired /KUpgraded ( ), Abandoned ( )
by: 10nd v)�4—
at V
has been installed in accordancewith the rovisi ns of. 10 CMR 15.00 (Title 5) and th app
proved design plans/as-built plans relating to
application No. dated Approved Design Flow 07 (gpd)
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Installer --- ��n . q �t tle-VZ AtA
Designer: '1 ,' Inspector: f V Date:' I
The issuance of permit shall not be construed. a guar tee that the system will function as designed.
No.�)�� i 4"� �A� %vjB� s j�/i- FEE`S•. i
/ b -� l CO MON I..TII O �' ASSS�I�' C44USETTS
Board of Health,V Moir * , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(// S Upgrade( ) Abandon( ) an individual sewage disposal system
at �� ()(,�(�E�>)�o,�rC I, t ii- Afak as described in the application for
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Disposal System Construction Permit No. dated � ..� � ✓�
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Provided: Construction shall be completed within 41x # s oof the date of this permit. 1 peal condition m t be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date k " Board of Health f y tel"