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HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSACHUSETTS Board of Health, ,M Old} , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION FEE' CTX�l7•VV {/e� a JUL. o 2018 R,14 IT Application for a Permit to Construct( ):Repair( ) Upgrade( ) Abandon( ) 0 Complete System O Individual Components Location g Owner's Name Map/Parcel# �te Address J% at (jL 1) S W 4 J �)/CL G -e Lot# Telephone# ` Installer's Name A20•e C) %, S Designer's Name Address ©a� �, li'6 f✓ 5 Address Telephone# Telephone#'XL Type of Building /✓ !f[/ L fLot 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 providedgpd Plan: Date Number of sheets Revision Date Title Description of Soils) Soil Evaluator Form No. Name of.Soil'Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS / K -e V ), W Ct4 e-<, The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree place the systei in operation until a Certificate of,. Compliance has been issued by the Board of Health. Signed Date Inspections H 1DC't �' � J 9 °' A FEE ~f j /00 COMMONWEALTH OF MASSACHUSETTS (A' Board of Health, A- 0 jJ14 , MA. ?r7-lf CERTIFICATE OF COMPLIANCE l Description of Work: ❑ Individual Component(s) O Complete System 44ee The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( } by: at has been installed iA accordance with the proviisi°+ons o10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No., 1 , dated 7' 5 /� Approved Design Flow (gpd) Installer 1 1. C Designer: Inspector: �``Ar"1� Date: The issuance of this permit shall not be construed as a, guarantee that d, system will function as designed. No. �� �, j �1 ".� ) FEE ' S„ 00 COMMONWEALTH Of MASSACHUSETTS Board of Health, y&gN 80T)l , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to;_ Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual, sewage disposal system at C;Ly, % t b SjJ rA i�,l� 1 �/� as described in. the application for Disposal System Construction Permit No. � % Z dated -7 - Provided: Construction shall be completed within three years of the date of this er All local conditions must be met. Form 1255 Rev. 5/96 A.M.;Sulkin Co. Chadeslown, MA Date / ri� Board of Health