HomeMy WebLinkAboutApp-Permit-Compliance' y 1
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t COMMONWEALTH Of MASSACHUSETTS P0;2,
)OZX. 4 el � / Board of Health, YAf MOJT H , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (,.,y)Repair(.) Upgrade( ) Abandon( ) omplete System Q Individual Components
Location ol-5
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Owner's Name ifs A - G
Map/Parcel#
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Address Li
Lot#
Telephone# -7741 — pt
Installer's Name
I` , ��Q /�dJ C04
Designer's Name65C Cr -0U ia
Address
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Address -3 L1 2 Ijio Lv&
Telephone#
S
Telephone# so &-
Type of Building
Dwelling - No. of
Other - Type of Building, No. of persons
Other Fixtures
Design Flow (min, requ' ed)
Plan: Date (010q& 7
Title
Description of Soils) _
Soil Evaluator Form No.
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow Design flow provided 77—gpd
Number of sheets Revision Date
J I a.
of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS S -e P !S j Z U -f,
Date of Evaluation
Theundersigned a s to ` all the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t t to pfac ee $6 ' o` til a Certificate of Compliance has been tissued by the Board of Health..
Signed C/ Date 16
Inspections
No. e1f� t }i .-113 —3Ylf'c- / FEN:
CNMONWEALTH OF MASSACHUSETTS
Board of ?'health, VAIPMOUD4 MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) fmplete System
The undersigned hereby certify that the Sewage Disposal System; ConstructedcL e, Repaired ( ), Upgraded ( ), Abandoned
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S 17 i stalle i cLbr e �(ntn ule pit`»oVisions 0 CMR .15.00 (Title 5) and the a proved- design -plans/as-built plans relating to
application No., dated Approved Design Flow (gPd)
Installer
Designer: - Inspector: �i ` `` Date: _
The issuance of this permit; shall not be construed as a.guar tee that the system will function as designed.
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COMMONWEALT14 Of MASSACHUSETTS
Board of Health, V"'M 6 (mi , MA.
ISI P® L S1'STEM CONSTRUCTION PERMIT
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Permission is herebygranted to,•„ Construct(v,1,, Repair( ) Upgrade(.. �' Abandon( ) an individual sewage disposal system
at lQ :y`s �� c;., �' 1 as de'scribed in. the application for
Disposal System
Provided: Construction shall be completed within three years of the date of this permit . All local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Chadestown, MA Date f d' hoard of Health ' L.