HomeMy WebLinkAboutApp-Permit-Compliance• � No. ,.
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lCk4l Z.(4 46COMMONWEALTH Of MASSACHUSETTS
Board of Health, Yl ill , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair (V�'Upgrade( ) Abandon( ) ❑ Complete System Qdndividual Components
Location
, .5
Owner's Name
Map/Parcel#
7 '
Address
Lot#
Telephone#
Installer's Name
�
Designer's; Name
Address
4\,
Address
Telephone#
g
Telephone#
Type of Building Lot Size sq. ft.
Dwelling- No. of Bedrooms Garbage grinder.( )
Other Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of goil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR
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 Date.
r
Inspections
No. �CJIi.---_Stu'dl..�� FEE.V1."
COMMONWEALTH OF MASSACHUSETTS
Board of Health, _ 0 tib , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (t,-�, Upgraded ( ), Abandoned ( )
by: V^ "
t C'
at !, Irk -'>-
has been installed in accordance with the Provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans re'lat'ing to
application No., 1 r dated '" �� "' l Approved Design Flow - (gpd)
Installer � 6,
Designer: Inspector: Date:
The issuance of this permit shall not be .construed as a guarantee that the system will function as designed.
No. { ) �'1� iii 'f t..r ' G�.-�a_ �...� „� t• 'w. � 04- � FEE ,...
COMMONWEALTH OF MASSACHUSETT
Board of Health, _ MMO 0711 MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is'hereb ranted to; Construct Re air Upgrade ( ) Abandon an individual sewage disposal s
Yg ( ) p ( ) pg stem ( ) g P y
at as described in the application for
Disposal System Construction Permit No. 1 7 dated
Provided: Construction shall be completed within three years of the date of this pex i� 1 local con itions must be met.
1k, f
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date -o r Board of Health%