HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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COMMONWEALTH OF MASSACHUSETTS
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- zu. � f �, �°ard of Health, l'113T1� , MA. ('� � �.�d°�-£' �k`, l�-t r��r� %
APPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTIO 'PERMIT
I At lication for a Permit to Construct( ) Repair( Upgrade (V/Abandon O -1mplete System Adlndividual Components
Location�-]Nkl
Cis
Map/Parcel#
Address .t.�
Lot#
Telephone#
Installer's NamemWs
Designer's Name
Address 7V Cu
L Address 12. S
Telephone#
Telephone# '
Type of Building .�r
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (mil . required
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
Number
DESCRIPTION OF REPAIRS OR ALTERATIONS
S'k u_ Shy
Calculated design flow
Name of Soil Evaluator
No. of persons
Lot Size j()jjbjsq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date -
of Evaluation
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The undersi ed a, es to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further gre to n t place the system in operation until a Certificate of Com liance has been issued by the Board of Health.
Signed Date
Inspections
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No .. �t f. `� COMMONWEALTH ®F MASSAC I SETT
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Board of Health, �A) A? 1 1 9 4L1• 0!. 03�23/?�
CERTIFICATE Of COMPLIANCE
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Description of Work: I'`fndividual Component(s) WComplete System
The under ,ned herebyahertify4hat the Sewagppispo al System; Constructed ( ), Repaired ( ), Upgraded (v), Abandoned ( )
by:
at P 'Vi d I"Lb'i'P"'I(v'
a
has been installe5I in acgordance with the provisions of 310 CMR 15.00 (Title 5) and the appl:gved design plans/as-built plans relating to
application.— o- dated 71"' P Approved Design Flow ^ �"t' (gpd)
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Installer%gt
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Designer: i a d 1 @}„ { sl+ 6' htspectot , x / r rd Date: r
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. ,F
No. E�:��.`�4t;.�6,:-`,i.w,c`..r (°4.)}(.�,) E---r'C*„. _ • FEE "S6.o(}
COMMONWEALTH Of MASSACHUSETTS
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Permission is hereby granted to; Co
at :1u 1`k a TR (
Disposal System
Provided: Construction
Form 1255 Rev, 5/96 AM SAM Co CFa WOWRM a Da