HomeMy WebLinkAboutApp-Permit-ComplianceNo. _V00CA-7-378 6 id—tri.' 1'1PHUSETTS
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7 -fl C®MMONW TLI IF MAS"
vele � A 't��7 Board of Health, �qgMQ L 4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
LUplication for a Permit to Construct( ) Repair( ) Upgrade(.-�/AbandonO - Ca Implete System O Individual Components
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Vocation 51713
Owner'sName
Map/Parcel# /)I �, ��
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Address 3D
Lot#
Telephone#
Installer's Name
Designer's Name `
Address
% Address®
Telephone# —
Telephone#
Type of Building 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) 3 d 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 Date of Evaluation
P
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 agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. lbo, l �7 B9 A(4 10, i• 'EE 00
�" ' l ,1 7�
` 1 17-9 Board of Health, Y49M U174 , NIA. ®
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CERTIFICATE Of- COMPLIANCE
Description,of Work: O Individual Component(s) %Er mplete System
The unde si fired hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.(f)"Abandoned ( )
by: , 41-- G'' ti s
at = M
has been installedy*a_accprdance with the ovis - ns. o910 CMR M00 (Title 5) and_ roved design plans/as-built plans relating to
app-------- o /��, dated_c/ Approved Design Flow (gpd) (fit ��y . ®,!], �✓y
Installer L
Designer:�Js.wd Cr. +-.u'Inspector: f f Dater ��
The issuance of this permit shall not be constriied as a guar et that the system will function as designed.
17 � c 1 '_
No. �) W�: �-�i-"1✓ u �.-���1"!..�� fi � �1�-e i FEE. .a6.�)�
COMMONWEALTH OF MASSAC14USETTS
Board of Health, A-YZM 0 VTjq- MA.
DISPOSAL SYS - CONSTRUCTION ]PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(., -3 -Abandon( ) an individual sewage disposal system
atr'''�Z- as described in the application for
V r
Disposal System Construction Permit Nc 1 . > dated 17
Provided: Construction shall be completed withitrt�M;L date of thiT All local conditions must be met.
Form 1255' Rev. 5/96 A.AySulkin Co, Chtown, Mn Date /"Board of Health
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