HomeMy WebLinkAboutApp-Permit-ComplianceNo.(/ 4 --)-1 co -
FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health,i��:RiiMOUITH HEALTH DED---
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APPLICATION FOP, DISP0MYfi@V9PRM VOMIRUCTION PERMIT
Application for a Permit to Construct( ) Repair (v<Upgrade ( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location -3 5-
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Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
Designer's Name
AddressC� Zc► ,1 j
Telephone# QNP_ vi?
0 . C(O�5-5"
Address
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es to t to place tem in operation until a Certificate of o fiance has been issued by the Board of Health.
Signed / Date
Inspections
No. � COMMONWEALT14®f MASSAC14USETTS FEE All,
Board of Health, "/ t "t MA. j
CERTIFICATE OF COMPLIANCE
Description of Work: 'OrIndividual Component(s) ❑ Complete System
The undersigned hereb certify that the Sewage Disposal System; Constructed ( ), Repaired (✓f Upgraded ( ), Abandoned ( )
by:
at 3 Sf `��� A✓.
has beery installed in ccordan,&e with the provisions of 310 CMR 15.00 (Title 5) grid the approved design plans/as-built plans relating to
application No.0"I.`-� Z �, dated G �i ' U4 Approyed Design Flow (gpd)
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Installer -94 //,/ ,�, ;j /,/ I / j -
Designer: Inspector: �!)7 Date: �1 4//0G/
The issuance of this permit shall not be construed as a guarantee that the system will Yimction as designed.
No. C} � ll�^'�l VVJ ✓ FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, L161�'1`�y t// MA.DISPOSAL SYSTEM C6NSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
at 3,� V 4,6,x• , Cr d,' r—k``II l _ / �1 as described in the application for
Disposal System Construction Permit No. Qq � � , dated G^' `1
Provided: Construction shall be completed within tnTer7ears of the date of this permit. l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
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