HomeMy WebLinkAboutApp-Permit-ComplianceNo. �48—� GO ¢i
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C / COMMONWEALTH Of MASSACHUSET S
Board of Health, _ JO lei' MA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair 011Upgrade ( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
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Owner's Name y� �--
Map/Parcel#
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Address U(:� SLA `V
Lot#
Telephone#
Installer's Name
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Designer's Name
Addressl
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Address
Telephone #
L13d- Ct-(Q-5
Telephone#
Type of Building kQ i I t+) -c4. -k Lot Size
Dwelling No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Pian: Date
Title
Description of Sbii(s)
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Soil Evaluator Form No. Name of Soil Evaluator D,atte_ofu Evaluation
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DESCRIPTION OF REPAIRS
The undersianed agrees to install th ve escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre s to no o plac a yste operation until a Certificate of Compl' ce has been issued by the Board of Health.
Signed �Date --LI i� <c°�--
Inspections
No. FEE'
COMMONWEALOE I�' ASSACHUSETTS 1�' e � � C 1 ZY-7�
' Board of Health, Y D� , , MA. A-�
CERTIFICATE OF COMPLIANCE O
Description: of Work: C3 Individual Component(s) El Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (r�, Up rade (a)Aak;2(4'
t
by: `;i'' C `� �1` t v ` t t �L.� ..; ;., . (( t- 1 t R^� ' C7, e a i ? k A jb,- N)
at j
has been installed in accordance with the provisions^ions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated' . Ar Approved Design Flow -- (gpd)
Installer = 7, it i `i,� � v`- t _ � ,i i , . , (! 'D A N A S'PPA Lm A
Designer: "" Inspector: — Date: —
The issuance of this permit ;shall -not be construed as a guarantee that he system will function as designed.
No,`}�6c ,��r�`P� j�tg}�.j��¶`5��7
1 / 'l.OMMON V'9' EA LT14 OF MASSACHUSETTS
SETTS
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Board of Health, \/A11.Dln-4nt rn:k , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ,y Upgrade( ) Abandon( ) an individual sewage disposal system
at
11 Ci �. %' as described in the application for
I �J{' ..� �'•l �
Disposal System Construction Permit No. dated,c>...
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 _ /XBoard of Health