HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6�+t*1� -- I /'x33V b
/ 7- COMMONWEALTH OF MASSACHUSETTS
Board of Health, YU&OVM, MA.
FEE 55 W
Ck400
RECEIVED
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION fRM IT
HEALTH DEPT.
Application for a Permit to Construct( ) Repair(-� Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
Location oy
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Owner's Name111
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Map/Parcel#Address
Lot#
Telephone#
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Installer's Name R 0 �j--�-
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Designer's Name
y
Address
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Adress
Telephone# e` — d4
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Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building —
Other Fixtures
Design Flow (mina required)
Plait: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( }
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �.Pl �CQ-
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 plac a syste�Weration until a Certificate of Compliance has been issued by the Board of Health.
Signed�2, � 6 r Date /
Inspections
No.1- 1 s'3s'['
4.
C®MMONWEAILTII OF MASSACHUSETTS
Board of Health, 80TM MA.
CERTIFICATE Of COMPLIANCE
FEE
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Description of Work; WIndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in accord n, with the provisions of 310 CMR 15.00 (Title 5) and the apemproved design plans/as-built plans relating to
application No., L, dated f:3 — Zg :�approved Design Flow (gpd)
Installer ` ' ' ')2 )
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. 114i:C. % `�� 41� FEE
COMMONWEALTH OF MASSACHUSETTS c6 ovi i L4
Board of Health, � Q lL;" A MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(- Upgrade( ) Abandon( ) an individual sewage disposal system
at '%r% N as described in the application for
Disposal System Construction Permit No. dated 7
Provided: Construction shall be completed within three years of the date of this permit! All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date pard of Health AhC�
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