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HomeMy WebLinkAboutApp-Permit-ComplianceNo. O C- 7� ON -FEE I V "O?% on- Board of Health, I Af=MB Yn4 MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - .Complete System O Individual Components Location 0 a a e e Owner's Name /W0 1" Map/Parcel# Address Lot# Telephone# Installer's Name Designer's Name��� 11 Address 7 i , )65'e to Address L, `��u U `-1 I p �%v1 Telephone# V If d (, Telephone# /- '7,o o Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder( Other - Type of Building No. of persons Showers O,'Cafeteria Other Fixtures , Design Flow (min. required) gpd Calculated design flow Design flow provided l V� X gpd Plan: Date 7 —Y Number of sheets �_ Revision Date Title �r Description of Soils) Ith Soil Evaluator Form No. Name of Soil Evaluator 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 agrees to not to lace the to in operation until a Certificate of. Compliance has been issued by the Board of Health. Signed Date Inspections '/- %t 3A AOV4 0_ No. , ll l' . , 7 .f;j� (�j FEE Board of Healtl; CERTIF ATE OF COMPLIANCE o� - Description of Work: 0 Individual Component(s) Complete System The undersigned hereb ce tx that th Sewa y1Dis oral est Cvonsr�t g y Lfyl p �'' ed ( ), Repaired ( ), Upgraded!1bandon,ed ( ) by: 7 at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the ap v design plans/as-built plans relating to application No. dated'=f Approyed Design Flo pd) Installer ksa I ' r° 1.��r/ Designer: � n � G cri'=. e�' ` Inspector: �b4,n� g�� Date: a The issuance of this permit shall not be construed as a guarantee that the system will functiop as designed. No. ` i . `Q, ? f M COMMONWEALTH OF MASSACHUSETTS Board of Healtlt, ��� S.p , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to- 10 str 'ct(�j,l Repair( ) Upgrade{Abandon ( )an individual sewage disposal system at � �f' � f kill as described in. the application for Disposal System Construction Permit No. , dated,C;• Provided: Construction shall be completed withijL r '* of the date of this perim Jocal conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date/! / J Board of Health C(( rr�