HomeMy WebLinkAboutApp-Permit-ComplianceNo. og iAIDC49 ��A
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, )6V= 0(rj 14 , 11M.
FEE;
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APPLICATION FOR WPOW. WON CONSTRUCTION PFIP'IT
9�-�lkidaf" Application fora Permit to Construct( )'Repair,( ) Upgrad AbandonO - ❑'Complete System Components
Location
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Owner's Name
I Map/Parcel#
077,
Address
Lot#
Telephone#
Installer's NamCL
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Des igner's'Nam
Address
Vk—k� Address
Telephone#
Telephone# .--.
Type .of Building "t Cfi(lr1 Lot Size sq. ft.
Dwelling- No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers (' ), Cafeteria
Other Fixtures.
Design Flow (min. r quire') `1 gpd Calculated design flow Design flow providedj�d
Plan: Date Number of sheets _ Revision Date
A1114 -
Title b
Description of Soil.(s)
Soil Evaluator Form No;. Name, of Soil Evaluator
DESCRIPTION OF REPAIRS OR AI TERATIONS
Date of Evaluation
The. undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions. of TITLE 5 and;
further agrees t to place tem in operation until a Certificate of om H' a has been issued by the Board of Health.
Signed Date 1
Inspections
No, Ci'(j ' 1FEE
COMMONALTH OF MASSACHUSETTS
Board of Health, i'TlGN01Jl )n4 , MA.
CE RTIFICATE OF COMPLIANCE
Description of Work: nZndividual Components) ❑ Complete System �r
The undersigned hereby certify that the Sewage Disposal System,; Constricted ( ); Repaired, Upgraded( ),Abandoned (.
by: 6Z C C S
at vC 1"
has been installed .♦' raccorda ce with t le rovisions of 310 MR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. "" dated Approved Design Flow' &d)
q.,
Installer
Designer: 0 Inspector: - Dater
The issuance of this permit shall not be construed as a guarantee that td, system will function as designed.
No. � i+� kl�gz Li's FEE . -
COMIM ONWE-ALT14 Of ASSACHUSETTS� c) q
Board of Health, MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby.granted to;' construct( ) Repair( ) UpgradesO Abandon( ) an individual sewage disposal system
at l P i� as described in the application for
d
Disposal System Construction Permit�No. , atedX2
J
Provided: Construction shall be completed with u_thr� of a date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M.Sulkin Co. Chadeslown, MA Date" =1 Board of Health