HomeMy WebLinkAboutApp-Permit-ComplianceNo. pW, FEE t -
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RGECOMMONWEALTH OF MASSACHUSETTS
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Board of Health, ( (�) �' MA. r� ' I
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION 1 "-- H DEPT.
Application for a Permit to Construct( ) Repair( ) Upgrade( -Abandon( ) - 0 Complete System alt-ilvidual Components
Location
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Owner's Name Cvr-J P "L
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name
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Designer's Name
Address ��
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Address
Telephone#
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T.elephone#
Type of Building 1" r/� �� 't ��� Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder (41-
Other - Type of Building No. of persons 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)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Al G'
The undersigned agrees to install the jl a dividual Sewage Disposal System in accordance with the provisions of TITLE 5and
o p further agrees to not lac car o era ' a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
COMMONWEALTH OF MASSACHUS ETTS
Board of Health;%UAC01-4
ix CERTIFICATE OF COMPLIANCE
Description of Work: Q16dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (,,)/,Upgraded ( ), Abandoned ( )'
by: V9 &"-it h-+�
at i6 G 0 W-\
has been installed in accordance with the provisions of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated. 7 Approved Design Flow (gpd)
Installer slt,�-��-
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a,guarantee that ICe ystem will function as designed.
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, M n k yj�A , Am.
DISPOSAL SYSTEM CONSTRUCTI®NT PERMIT Y
Permission is herebygranted to; Construct( ) Repair( Upgrade ( ) Abandon ( ) an indi ndual,sewage disposal system
at -ak (-OeEgo t y e, as described in. the. application for
Disposal System Construction Permit No �-� % ; dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M.,Sulkin Co. Chadeslown, MA Date�—4�F Board of Health
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