HomeMy WebLinkAboutApp-Permit-Compliancel k-IZ I COMMONWEALTH OF MASSACHUSETTS
A,' l/ A 11,1jg-iil�Board of HealM, -P y4,9 r10
Fee $6v`m
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APPLICATION FOR DISPOSAL BSI YSTEM CONSTRUC"ndi
N PERMIT
Application for a Permit to Construct( ) Repair ( ) Upgrade Abandon ( ) - ❑ Complete System dual Component O
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Location
Owner's Name w- ~
Map/Parcel #
Address '" 41 � W00C) t-.(.
Lot #
Telephone +q 19 S To 9'9
Installer's Name
Designer's Name ��IA�(d e Ln
Address
Address
Telephone # ?a(�
Telephone # 5O -Z_ , 5
Type of Building Lot Size sq. ft.
Dwelling -No. of Bedrooms Garbage Grinder ( ) Yes ( ) No
Other - Type of Building No of Persons Shower( ) Cafeteria( )
Other Fixtures --�
Design Flow (min. required)�
gpd Calculated design floW4�; gpd Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator - Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
Nob
T e undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place
ti. system in operat i until a Certificate �of,,Compliance .hass been issued by the Board of Health. r n r
Si ned i V �' ► c ka,,`�^ Date
Inspections
DEP APPROVED FORM 5/96
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11
No: t ." `9 Fee �S5,
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COMMONWEALTH OF MASSACHUSETTS 0Y-�
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Board of Health, >/fA 12M 6 0 - "
CERTIFICATE OF COMPLIANCE
Description of Work: dividual Component(s) ❑ Complete System t
The undersigned hereby certify that the ( Sewage Disposal System: Constructed ( ), Repaired ( ), Upgraded )*Abandoned( )
a
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. `` dated 'AO( Approve Design Flow (gpd) , y
Installer i ,i'i�ldl�t 1 A.(,;,t r7 '� Iri l0 . t. .. ' � _ k L—:y�""1 ,N) C S
Designer d 1'.14 �. i-)Ie Inspector �'" 111 Date 0� ,
The issuance of this permit shall not be construed as a guarantee that system will function as designed.
DEP APPROVED FORM 5/96 t
No.,_0 c. 4 3 — `3 t ! I,.'d � C 4+f) 5 e iM C i Ari\r —I Fee
COMMONWEALTH OF MASSACHUSETTS * 1 i �32_
r Board of Hea1th,.Qx1ae - YA 9(V(O 0 -n+
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to: Construct ( ) Repair ( ) Upgrade Abandon ( ) an individual sewage disposal system
at_.'' A i� fA i! Y ± iA- ` L t as described in the application for Disposal
System Construction Permit No. �� '7 ,dated
DEP APPROVED FORM 5/96 Date Board of Health
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