HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE isy
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L-� Board of Healthl 14'G, , MA.
APPLICATI®�1 R DISH&T"WtMMUCTI®N PERMIT
Application for a Permit to Construe Repair( ) Upgrade( ) Abandon( ) - Complete System ❑ Individual Components
Location 0Owner's
Name
Map/Parcel#
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Address
Lot# j
Telephone# 39
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Z WE
Installer's Name
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kt G
Designer's Name01TSa
/el
Addressurn
U R
Address
Telephone# _
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Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size '3 sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures ((
Design Flow (min. required) L4 0 gpd Calculated design flow Design flow provided b� 7 8 gpd
Plan: Date Z _ Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
FX
Name of Soil Evaluator _9lir[M Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The unders' ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e o' oft the a in operation until a Certificate of C m � c has been issued by the Board of Health.
°Signed i Date
=Inspections !` ¢
Lz
No.
/ l� / FEE'S/
COMMONWEALTH OF MASSAC14USETTS C6p 71' �9 �
Board of Health, pn Uu.n4- MA. U
CERTIFICAA Or COMPLIANCE
Description of Work: ❑ Individual Component(s) 6;11 eomplete System
The under 071M
d hereb certify that the Sew,a3e Dispo1s/al System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: 1�4?C�. L %L� ({'�i L
at
Le 14
has been installed i ace r a ce with the ovis ons of 10 CMR 15.00 (Title 5) an t aa°ved design plans/as-built plans relating to
application No. // ^�yd , dated ^� Approved Design Flow ��'(gpd)
Installer P/.I / Z7 (�) -- 4
Designer: Inspector:_ Date: 7 -616
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
No.P
//Z� FEE f ` J
C®MMONWEALT14®F MASSACHUSETTS
Board of Health,G
DISPOSAL SYSILM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at & R1 - t� + ' �as described in the application for
Disposal System Construction Permit No. L14
^ y , dated
Provided: Construction shall be completed within TFWs� the date of thispermit. All local conditi ns must be met.
Form 1255 Rev. 5/96 A.M. SWkin Co. Boston, MA Date/1 I 04Board of Health
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