HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, ��9-�-91.0 VT14 , Am.
FEE f�°00
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APPLICATION FOP: DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application fora Permit to Construct{ ) Repair,( ) Upgrade�ndonO - L9'Complete System O Individual Components
Location
Owner's Name i e G9/ U es,
Map/Parcel#
Address
Lot# 2
Telephone#
Installer's Name
o
Designer's Name 014
Address
/t y
Address �a �• L �jr% T
Telephone#
G� ®�
Telephone#
Type of Building Lot Size, sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( }
Other -Type of Building No. of persons Showers ( }, Cafeteria ( ).
Other Fixtures
Design Flow (min. required) y �% 6 gpd Calculated design flow Design flow provided gpd
Plan: Date / 2 — / Number of sheets / Revision Date
Title
Description of Soil (s) i'i G' 14
Soil Evaluator Form No. Name of Soil Evaluator /2o, 6,4.e
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation �— v
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 -and•
further agrees to not to place the s
ysteip in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed_ Date
;Inspections
i
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No. ✓` �' ` 4�/ � " { � _ r FEE
COMMONWEALTH OF MASSACHUSETTS-). fle � _ -7 00
Board of Health, yo , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: U Individual Components) Complete System
The undersigned hereby certify that the Sewage Disposal Sy tem Constructed O , Repaired ( ), Upgraded { j,, Abandoned O`
by re i 7w
at fe
has been installed in accorclance with the provisions 31.0 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No. 1� dated]` �l Approved Design Flow (gpd)
Installer A4e ,e _ o %'
Designer: ed, C c: 41, lY/,-Inspector: r 94Aa�',� Date:
The issuance of this permit shall. not be construed as a guaran0e that the system will function as, designed.
No. �� 1 _ FEE J, t✓'
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ��O 1 4- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission ishereebygranted to; Construct(t.,)" Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
as described described in. the application for
Disposal System Construction Permit No �''401 •, dated 1110
,s
Provided: Construction shall be completed within tibs o , the date of this permit. All local con iti s must be met.
Form 1255 Rev. 5/96 A.M."Sulkin Co: Chadestown, MA Datef tJ� ! e Board of Health