HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEAVUUTH HSACHUSETTS
EALTH DEPT. /
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1 Board of Health, 1146ROUTE 2R , MA.
APPLICATION FOP, DISP01 MWeMWCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade((„) Abandon() - Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
Address a C
Lot#
Telephone# f I - oZ 1
Installer's Name -
Designer's Name
Address d r
Address ,�4
Telephone# J
Telephone`#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
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 Soils) gyp/ #=,�
Soil Evaluator Form No. Name of Soil -Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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The undersigned agrees to install the above describedrh dividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree& to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date T $
Inspections J(11./ iif7dn/1�� Eli • (�, d 6i001 d 0 •0 ,ra C� ` iv��
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No. / `'7 7s FEE
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COMMONWEA T14 Of MASSACHUSETT -
Board of Health, MA. f
CERTI ICA ®f COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System t
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ) , Repaired .(d , Upgraded ( ) , Abandoned O
by: �-
at <a;
has been installed in accordance with the provis ns of 3 0 CMR 1900 (Title 5) and the approved design plans/as-built plans relating to
application No. iJl , dated .2 " � Approved Design Flowfl�(gpd)
Installer Sre ' - I/
Designer: /� &_AP /! . Inspector: �GL! Date:
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. � FEE
Board of Health MA.
,
DISPOSAL SYST19CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (4-< Upgrade ( )Abandon ( ) an individual sewage disposal system
at (/t�i2.vzvirl��i/ as described in the application for
Disposal System Construction Permit No. 0 -I-q-S , dated •- 4 -if
W-Z j
Provided: Construction shall be completed within thVe-e-y-erM of the date of this permit. All I cal conditions must met.
AA Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA //�� Date ' Q Board of Health