HomeMy WebLinkAboutApp-Permit-ComplianceNo.JL_ �02�(AD-� Z� FEE'��YtJV
COMMONWEALTH OF MASSAC14USE TS
7,Y13 Beard of Health, �!%��'�toU� MtL
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCT���������PERMIT
mcJQ4fidividual Components
Application for a Permit to Construct( Repair( Upgrad AbandonO - ❑Complete Syste - p
Location <��.
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Owner's Name
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Map/Parcel#
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Address
Lot#
Telephone#
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Installer's Name
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Designer's NameEAES
Address :d% •
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AddressP.
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Telephone#
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Telephone#
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Type of Building Lot Size. j Q sq. ft.
Dwelling - No. of Bedrooms Garbage grinder(
Other - Ty
pe of Building No. of persons Showers O, Cafeteria. ( ).
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Other Fixtures
Design Flow (min. required) `J gpd Calculated design flow 330, 30,
Plan: Date i �Sl l Number of sheets
Title
Description of Soil (s) Cl l AI J Lo hi nI
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided gpd
Revision Date
Date of Evaluation
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 tem ' ope ation until a Certificate of Compliance has been issued by the Board of Health.
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Signed Date
No. 7,s' C� °,Jt -11-7-09 38 1ALTH OF MASSACHUSETTS FEE i +��, � i,./
COMMONWr
Board of Health, A P- 0 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work:_,,Ql' ividual Component(s) O Complete System (�'w`✓ �)f` {A
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded -(..);abandoned O'
by:
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the I roved design plans/as-built plans relating to
application No. ! , dated - ` %�!° . Approved Design Flow (gpd)
Installer ~t- iI3 �. -y
Designer: C2--1 Vey- e i W, Inspector: f f '•: �'i.�`f �r'. Date:
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The issuance of this permit shall not be construed as a guarant"e that the system will function as designed.
j ~ % 57 COMMONWEALT14 Of MASSACHUSETTS
Board of Health, _ YXA,/�1(,).(,ny , NM. `
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
009-2
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (._)--Abandon( ) an individual, sewage disposal system
at ° ' ��_ '� 4s' �' : C` as described in the application for
14 t
Disposal System Construction Permit No. 3 , dated -` %I '-{1
Provided: Construction shall be completed within 4L ats o hedate of this permit. N1 local conditi ns must be met.
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Form 1255 Rev: 5/96 A.M. Sulkin Co. ChaBestown, MA Date '"� �` � Board of Health
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