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HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSAC14USETTS . Board of Health, r' 014 , Am. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( - ❑ Complete Syste Individual Components LocationMIS Owner's Name � "b0 Map/Parcel# `� Address J VWk O Lot# Telephone# Installer's Name Designer's Name Address ��1 jl ' •Z�� ' 1 Address R 26 N v Vt WAS Telephone# © _ Telephone# Type of Building Dwelling - No. of Bedrooms Calculated design flow sheets of Soil Evaluator No. of persons Lot Size sq. ft. Garbage grinder( ) Showers ( ), Cafg�gAia Design flow provided RC1 gpd Revision Date _ Date of Evaluation The undersigned agrees to'psyste v escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and o1furtheragrees to notin eration until a Certificate of Fomipliance has been issued by the Board of Health. Signed Date i Inspections 3-7 4-1- COMMONWEALTH OF MASSACHUSET tb H 11 � t1 MA 0 kv FEE Board of ea t i, �, CERTIFICATE Of COMPLIANCE 1,,ee Description of Work: udi'vidual Component(s) ❑ Complete System , A ' 01 The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired pgraded ( ), Abandoned ( ) by: , atc-� has been installed in a application No. Installer 64'1-A C with the p ;ovisions of 310 CMR 15.00 (Title 5) and e p oved design plans/as-built plans relating to dated Approved Design Flow gpd) •. _. � .. �^`. a -1,. `Designer: �4�4C'9 Inspector: Date: -r The issuance of this permit shall not be construed as a, guart that the system will function as -designed. No. b t % _4 2--3 ./ _ — - (S F j' { G " FEE � s�CJCJ 7-- COMMONWEALTH OF MASSAC41USETTS IZZ Board of Health, yAgM 0 QMA MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( v)" Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No./ dated�j)`% Provided: Construction shall be completed withid�l�at s fSf t date of this per i All local condi ' ns must be met. Form 1255Rev. 5/96 A.M. Sulkin Co. Chadestown, Mn Date -Z oard of Health i'