HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSAC14USETTS G ��
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2 Board of Tealth, MA.
% APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PEWIT
" Application fora Permit to Construct( ) Repair(,) Upgrad bandou(} 0 Complete System ndividual Components
Location C d` ('—Q i
Owner's Name S Q )*Y
Map/Parcel# "77 M75 j V
Address
Lot#
Telephone# SOS— �4
Installer's Name wits oyk
Designer's Name sG�
Address
Address & O 7 `
Telephone# S
Telephone# ,38`O .- Q
Type of Building Lot Size (/y t/ sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) ?:2-� gpd Calculated design flow Design flow provided gpd
Plan: Datelv/W/ 7 Number of sheets Revision Date
Title
Description of Soil(s)S'o1
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS SNP?�gd--VT �
The undersigned ees o ` tallthe above crib d Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree noWtacee on until a Certificate of Compliance has been issued by the Board of Health.
1
Signed Date
t �— — /
Inspections Pi 1, 9 ` set Is
COMMONWEALTH OF MASSACHUSETTS
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Board of Health, lfiL.tYi1�r# , MA.'o
CERTIFICATE Of COMPLIANCE
Description of Work: al!S�dividual Component(s) ❑ Complete System /,�6�%
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ),'Upgraded (ZrA, bandoned ( )
atAi t C ✓1
has been inst&d in atckrdan 4n t, j;;X, io &3I0 CMR IV00 (Title 5) a
application No.. 4 dated z0 7Approved Design Flow
Installer
Designer: 1 t , t �? % i' 1- ,,14 l''if ft ector: e� 414
design plans/as-built plans relating to
rn.r�3� Date: �.1