HomeMy WebLinkAboutApp-Permit-ComplianceNo. MACHO
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, YM:Pa0QT , MA.
` APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Per 't to Cons ruc (}, Re O U grade Ab do> O ❑Complete System n Individual Components
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Location
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Owner's Name �. S
Map/Parcel#
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Address 17d O/ —
Lot#
Telephone#
Installer's Name
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Designer's Name. C0
Address
Address O lZa
Telephone#
Telephone#
Type of Buildingt l 6 ) ' / �¢ /r` eke � `/I.ot Size sq. ft,
Dwelling - Na of Bedrooms �S >a d/ Garbage grinder ( )
Other -.Type of Building N#.)o obverssy( }, Cafeteria ( )
Other Fixtures ` Z 'f ell/ 7F f rl
Design Flow (min. required) �/ %3S gpd Calculated design flow 6g— Design flow provided gpd
Plan: Date /O to -/% Number of sheets Revision Date
Title
Description of Sbil (s) c P/4111
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERAT ONS e GUS
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The undersigned agrees to insiall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees j�iqto pl e m in operation until a Certificate of Compli/ance h�f been issued by the Board of Health.
Signed Date
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� � L � COMMONWEA �� M ��� [US TTS L ,
Board of Health, �&M ti t i i lei- , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ),.A andoned O
by:
at
has been installed in acc rdance with the provisions of 310 CMR 15.00 (Title 5) and the approved des* n plans/as-built plans relating to
application No. � dated 7 Approved Design Flow 17 32 gpd) 4�e4
Installer 04j (;� 1c1 0 P, t r• //, len 07
Designerle_>CY I1V�f'141�1(Y Inspectors ��'r'T _Date: -° /
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
No.�"1_�¢ --- 3/�t �d'��! �C.. FEE 45�
COMMONWEALTH OF MASSACHUSETTS Ckfae90
Board (f Health, o MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade'p Abandon( ) an individual sewage disposal system
at—C7 (ot� Gr ye)"3) ('til V F=_- / �' %' as described in the application for
Disposal System Construction Permit No. -ill/ dated
Provided: Construction shall be completed within three years of the date of this pernn All local conditions must be met.
Form 1255Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date y7 Board of Health
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