HomeMy WebLinkAboutApp-Permit-ComplianceNo. d�ON�DC'" v� l �� �, V
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4-4 COMMONWE T OX--ASSAC�HT�US
TS
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon( ) 0 Complete System 21ndividual Components
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Location �t,1
Owner's Name e e4-oe'n 6Fd�,
Map/Parcel# %�% %�� �d_r�
Address %od Bd cQ�v�- If
Lot#
Telephone#
Installer's Name
Designer's Name
Address 04 te) d� �' ,
Address a' J
Telephone#
Telephone#
Type of Building
Dwelling- No. of Bedrooms
Other - Type of Building —
Lot Size sq. ft.
Garbage grinder
No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) .2+c-O' gpd Calculated design flow Design flow provided' �?� gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s)��
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es to not to place the system in operation til a Certificate of Compliahce has been issued by the Board of Health.
Signed Date
Inspections
No. r FEE
COMMONWEALTH Of .l.` ASSAC14USETTS
Board of Healih, MA.
Am
CERTIFICATE Of COMPLIANCE
Description of Work: �vidual Component(s) ❑Complete System.'.
The undersigned hereby certify that the Sewage Disposal System Constructed ( ), Rewired'( ), Upgraded t~.andoned ( )
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has been installed ii ccoFda. e with thee„provisions of A10 C R i5. (Title 5) and tb, proved design plans/as-built plans relating to
application No. dated.V- 7.r �` . A proved Design Flow ,"�+�°> (gpd).
Installer l '7 �'` ' `s , �» l yr
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Designer: �+'�.� _ Inspector: ? Date:
The issuance of this permit shall not IV construed as a guar ee that the system will function, as designed.
FEE
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/�®MM�NA�T�I ��' MASSA�IIIJS�ETTS
Board of Health, �. (lr} , ,MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
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Permission is herebygranted to; Construct( ) Repair( ) Upgrade (-� ,Abandon( ) an individual, sewage disposal system
at as described in. the application for
Disposal System Construction Permit No. ,dated .
Provided: Construction shall be completed within l t the date of this pep'n All local cotr}d}tions niustbe met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date f to Board of Health