HomeMy WebLinkAboutApp-Permit-ComplianceNo. 5 0"C-2- U308 Q)L DT R t 1 "1 - 0 b 21 Co 2 FEE'
6 j CO1�' MONW LT Off' MASSACHUSETTS C gbh
1 / ldc Board ofllealth, , AA.
C'ATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(v,)'UpgradeO Abandon( ❑ Complete System ❑ Individual Components
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Location
Owner's Name '
Map/Parcel# V31
Address %� c z c5
Lot#
Telephone#
Installer's Name 4 ,.B E
Designer's Name VG
Address 14 'Tz C ^ldlary z.
Address _
Telephone#
Telephone#
Type of Building \SGSJi r_f\A icLA Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers O, Cafeteria ( ).
ether Fixnures
Design Flow (min. required) 330 gpd Calculated design flow Design flow provided 33& gpd
Plan: Date 1 O - ZO • 1B Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS IS00 A 10 - 5'T - D A3
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place tie system in operation until a Certificate of Complim`rce has been issued by the Board of Health.
Signed � Date 10 -1 z5- I
t
Inspections 1 11)9/)s — 5-od5 OK.
COMMONWEALTILOFMAS�-ACHUSETTS
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Board of Health, C. MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) CC<omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (%.-<Upgraded ( ), Abandoned
by:
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has been installed in accordance with the provisions of 3 0 CMR 15.00 (Title 5) and th a proved design plans/as-built plans relating to
application No. dated 4A3 �� t Approved Design Flow (gpd)
Installer R �- j, -,_4;n /\ �RC1?,t 15;C% 1., 1 n __--
Designer:. D sac Mca. Sn P1 Inspector:�,_� %