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HomeMy WebLinkAboutApp-Permit-ComplianceFEE Comm OF MASSACHUSETTS Board of Health, r/_�� , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) RepahX Upgrade( ) Abandon( ❑ Complete System Individual Components Location e, Owner's Name JeL141,04 Map/Parcel# �� Address 81 6/e eol Lot# Telephone# 5N- % ?C Installer's Name �� 1%e-7"7rf d V- �-S C Designer's Name Address Address Telephone# G 3Y 7 Telephone# Type of Building v�_' ff -N C �t Lot Size sq. ft. Dwelling - No. of Bedrooms 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 DESCRIPTION OF REPAIRS OR ALTERATIONS 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 to place tem' era ' a Certificate of CompVance has been issued by the Board of Health. Signed Date'�-1Z5— `A- Inspections FEE S Gl U COMMONWEALTH OF MASSACHUSETTS a� . �f H r2- �� ��- /Male �a0 ��-e- Board gfHealtla, y�AY1a�, MA. C ERTIFICATE Of COMPLIANCE Aalace /-) /d py Description of Work;Individual Component(s) ❑ Complete System The undersigned here,y certify that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded ( ), Abandoned ( } at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) ancj jh approved design plans/as-built plans relating to application No. 1 7- / 2 dated Approved Design Flow (gpd) Installer Designer: r''�Inspector: Date: The issuance of this permit shall not be construed as a guarapt�ee at the system will function as designed. No. COMMONWEALTH OF MASSAC14USETTS Board of Health, y ,Mp t i MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE . ©Q WS N 21tii� 3�1( Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at �f/ ( �l�°r�r� �di C j� �%� as described in the application for Disposal System Construction Permit No. �, dated Provided: Construction shall be completed within tb rs o tl'ie date of this permit. All local onditions must be met. Form 1255Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date . 1 Board of Health j ' f