HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH EALTH Of MASSACHUSETTS
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Board of Health., �i iZ-rvi�l� l , MA.
FEE
C i 35_7
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
Application for Permit to Construct( ) Repair( ) Upgrade(/ Abandon( ) - fd'tomplete System ❑ Individual Components
Location e
Owner's Name
Map/Parcel# �,�
Address
Lot#
Telephone# loe
Installer's Name
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Designer's Name
Address
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Pe Cam'
Address
Telephone# "'� ��
Telephone# �6VI f
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
No. of persons
Lot Size
Garbage grinder( )
Showers ( ), Cafeteria
Design Flow (min. required) d gpd Calculated design flow Design flow provided !L-efe, - 01gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil(s) D��.�i2!✓J
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS l _
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre s to not to place the system in operation a Certificate of Compliance has been issued by the Board of Health.
Signed Date —`� /60
Inspections
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CONl[M®N1L1I4 OF MASSAC14USETT o3
Board of Health, �-Iy4O �t t'�k , MA. �0 0
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify -that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (_4!Abandoned (, )
by: t _ 0 -^ W p lry''
at � E th�tTir .-
has been installe Q c y neee �Aisions of 310 CMR 1 .00 (Title 5) and th ap roved design ,plans/as-built plan; elating to
application No. dated Approved Design Flow "(gpd)
Installer
Designer:
The issa
Date
the system will function as designed.
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No. �iC-�� Cr1'1'r-i-5C- f A4 "u,� FEE
6 COMMONWEALTH I.TH OF MASSACHUSETTS g357
Board of Health, �,ff (LM A TM , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
atas described in the application for
-- , r
Disposal System Construction Permit No., dated
Provided: Construction shall be comp, eted within tbrs.of the date of this permit. All local condi ' ns must be met.
Board of Health Form 1255 Rev. 5/96 H.M. Sulkin Co. ChMestown, MA Date