HomeMy WebLinkAboutApp-Permit-ComplianceNo.y" Gil t� i ✓ kJ L J/ - I (� O 1 3 FEE c�C/
COMMONWEALTH OF MASSAC14USETTS
Board of Health, YPf PM Q 0 1-14 MA. J
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application !2='*
Per it to Can tract( ) Repair( Upgrade bandon - ❑ C plete System ndividual Components
Location
Owner's Name ) M
461JIYA6
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
HIAA au
Designer's Name 0
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Address
(ZJ- Ui&KA � Address
34,^1 J2
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Telephone#
_ (
Telephone# _
. Qj�'
Type of Building rr _ Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder {
Other Type of Building No. of persons Showers O, Cafeteria
Other Fixtures 7
Design Flow (min, required) b gpd Calculated design flow / / 7 Design flow provided u gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of. SoilEvaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 the system in operation until a `Certificate of Compliance has been issued by the Board of Health.
Signed 1C Date
Inspections
No.
E roo
COMMONWEALTH OF MASSACHUSETTS 14 s � C���
Board of Health, kIOW-I ' , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: jalIndividual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedpAbandoned
, ( )'
by: n i, � 01 6 i`1ier?J Lt" -1—
at Q
has been installed acco ace with the provis' n�s o`fA1.0 CMR 1.5.00 (Title 5) and thea >�ed design plans/as-built plans relating to
application No. / dated .eZ —7- �. Approved Design Flow (gpd)
Installer U' 11 'X� 1114 i f B � I C ^ 1 �►
Designer: TA % l y�� (o Inspector: Date: _
The issuance of this permit shall not be construed as a guar _e that the 1 4' system will function as designed.
No.l`��\� "� �> e�rilt�rFlalC $ iv1.CZt-E�7�1'
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Wril-- 19O QT74- MA.
DISPOSAL SYSTEM CONSTRUCTIONPERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon(
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at I( tj, J 1 A
Disposal System Construction Permit No.
9- f
FEE E))
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an individual sewage disposal system
— as described in. the application for
Provided: Construction shall be completed within t ekt�ee years of the date of this peri i . All local conditions iuust be met.
Form 1255 ev. 5/96 A.M. Sulkin Co. Chadeslown, MA„ )ate y �O Board of Health 1
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