HomeMy WebLinkAboutApp-Permit-ComplianceNo. OWDC-4F-3 �� l , � &��5 FEE' 1 61,00
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COMMONWEALTH OF MASSACHUSETTS
Board of Health,
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
4 plication for a Permit to Construct( ) Rep pgrade( ) Abandon( - 0 Complete System 'Ividual Components
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Owner's Name
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Address&W-f
Lot#
Telephone#
Installer's Name
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Designer's Name �lee4-1;e/`
Address
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Telephone#
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Telephone# -r-099� ka
Type of Building &L-96�. / Lot Size d Z up7 , l sq. ft;
Dwelling - No. of Bedrooms !q'ci./1 Garbage grinder {
Other - Type of Building No. of persons Showers ( ),'Cafeteria
Other Fixtures
Design Flow (min.
Plan Date
Title
Description of Soil (s) _
Soil Evaluator Form No
-of S t.z
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
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Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS L!nd
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with theprovisions of TITLE 5 -and
urther agrees to not to place the system in operation until a Certificate of Com lianc has been issued by the BoardofHealth.
igned as
Inspections
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COMMONWEALTH OF ASSACL-IUSETTS-d4 6 -1 y ' � r
Board of Health, �Y W t !1 t aji , M1•
CERTIFICATE OF COMPLIANCE
Description of Work: individual Component(s), ❑ Complete System(`
The undersigned hereby certify that the Sewage Disposal System; Constructed ( , epa` d ( ), Upgraded ( )> Abandoned ( )
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has been installed in a cordar ce with the provisions of 0 CMR 15.00 (Title 5) and t e approved design plans/as built plans relating to
application No.,_ z.:dated _ _ Approved Design Flow �� (gpd)
Installer
Designers .Jt. 4e7,5e,.1'' insp
The issuance of this permit shall not be construed as a
No.: l'L'
Board of Health, JM00371- , •
DISPOSAL SYSTEM CONSTRUCTION PERMIT
that the system will function as designed.
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COMMONWEALTH
{OMMONWLTH fiC MASSACHUSETTS ASSq(HUETTS
FEE
Permission is':hereby granted to; Construct( ) Repa4.�- Upgrade( ) Abandon( ) an individual; sewage disposal system
at % ��h+ —1 is e. z [ ln'YC as described in. the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three_ ' ' o the date of this p >i All local conditions must met:
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chaileslown, MA Date Board of Health —