HomeMy WebLinkAboutApp-Permit-ComplianceNd.' g(*DC-I8- 3G7 I
FEE'
COMMONWEALTH OF MASSACHUSETTS ck;Wtuc, V
Board of Health, )�&RMRM , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
pplication for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( - 0 Complete System KIndividual. Components
Location 9
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Owner's Name
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Map/Parcel#
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Address l q CLi
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Lot#
Telephone#
Installer's Name
Ca
Designer's NameMIA
Address
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Address
Telephone#
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Telephone*
Type of Building RGS1'b6i0Tt /4-L— _ 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 gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -TtUS—,XLL. Nj&A-)
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to place the system in operation until a Certificate of Compliance has been issued by the Board of Health..
Signed Date (0-/-;Z0149
Inspections
No. FEE t�v
COMMONWEALTH Of MASSACHUSETTS
Board of Health, f Lrnk MA.
CERTIFICATE OF COMPLIANCE 62
Description of Works kIndividuat Component(s), ❑Complete System -1
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (k, Upgraded ( ), Abandoned ( )
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. t dated aof App��
roved Design Flow `-�'""'~ (gpd)
installer t 1`
Date;
Inspector: / s
Designer:. � /`� � _ .�' 4 � �
The issuance of this permit shall not be construed as a,gua tee that the system will function as designed.
No.C_,O
paJCDe�
COMMONWEALTH Of MASSACHUSETTS
Board of HealtA, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Permission is hereby granted to; 'Construct( ) Repair (X) Upgrade( ) Abandon( ) an individual sewage disposal system
at d L(X)-rWi -Doo ( as described in. the application for
Disposal System Construction Permit No. dated%
Provided: Construction shall be completed within tat sof the date of this pe 't. All local condi 'ons. must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesiown, MA Date % Board of Health CelT