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HomeMy WebLinkAboutApp-Permit-ComplianceNo, i3otmc IB--6o (r' FEE 155` �- 'G9 COMMONWEALTH OF MASSACHUSETTS C S ZOO Board of Health, &(Li4.O V M , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - El Complete System ❑ Individual Components Location b �� Owner's Name Map/Parcel# 0 , ZO q Address Lot# Telephone# Installer's Name C�� %� G Designer's Name Address s� © Address Telephone# Telephone# Type of Building it Dwelling - No. of Bedrooms Other - Type of Building,_ Other Fixtures Design Flow (min. required) gpd Calculated design flow Plan: Date /'�� Number of sheets Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator Lot.Size No. of persons e sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria Design flow provided gpd Revision Date Date of Evaluation DESCRIPTION PF REPAIRS OR ALTERATIONS - 0 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree of to place the system pqration until a Certificate of Compliance 'has been issued by the Board of Health. Signed, --"Date Inspections N4301A DC. —1 C' _ j FEE COMMONWEALT14 OF MASSACHUSETTS Board of Health, �Or%4, , MA. CERTIFICATE OF COMPLIANCE �� o Description of Work; Individual Component(s) ❑ Complete System The' undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned by has been install ed�tacc/or anc with the provisions of 3 CMR 15.00 (Title 5) and the approved design plans/as-built plans.relating to .` application No. as �1 dated"7 7 V Approved Design Flow ----- (gpd) Installer U_C= fry' i?J /T f t Designer: "'r_ Inspector- 014wo 4 Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. v �! FEE; _ l� f COMMONWFALT14 Of MASSACHUSETTS Board of Health, �Pif-kQ a-q , AM. DISPOSAL SYSTEM CONSTRUCTION' PERMIT Permission is hereby granted to; Construct( ) Repair (r upgrade ( ) Abandon ( ) an indixndual sewage disposal system at 2 as described in the application for. Provided: Construction shall be completed within three years of the date of this pert1 local conditions must be met. Form 1255 Rev. 5196 A.M. Sulkin Co. Chadeslown, MA Date ! -/, Board of Health y- / {