HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSACIQJ TTS
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C & UTH HEALTH M:
Board of Health,114S R011TF 7R `' MA.
ffCIATION FOP, DISP(WTV" M?MUCTION PERMIT
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Application for a Permit to Construct( ) Repair(--r�pgradeO Abandon( ❑ Complete System ❑ Individual Components
Location ` s
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Owner's Name
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Map/Parcel#
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Address
Lot#
Telephone#
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Installer's Name
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Designer's Name
Address `
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Address
Telephone#
Telephone#
Type of Building _;Fc K _ Lot Size /. ,� f sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. requir d)gpd Calculated design flow
Plan: Date (0 Number of sheets
Title e / �: t A [9i-' 10 le r►-10O.CtiD
Design flow provided ✓ % gpd
Revision Date
Description of Soil(s) '[=-
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �'�,77 C`4 -) e0G.,414?C
Theundersi ed agrees to install the abov ribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to n t to place the a in o ration until a Certificate of Co ltpliarice has been issued by the Board of Health.
Signed Date
Inspections e -,23—
Y
No. 1? FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 21(Zomplete System �f-•—'�
The unders'. ned hereby certify that the Sewage Disposal System; Constructed ( ), Rep 'red ( Upgraded Abandoned ( )
by:.—
at
at
has been installed in accordance with therovisions 6f//3I0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application o. 1 1% , dated 9 7 ` b Approved Design Flow (gpd)
Installer
.3 Designer: K Inspectox,; Date:
The issuance of this permit shall not be construed as a guarantee that thesystem will function as designed.
No. L/l/�dQ v !/�f�d Qi�%yI FEE
COMMONWEAL19 OF MASSACHUSETTS
Board of Health, LA///. W14,414
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at ZZZ_ (J7%2��/�O�la'�/l�I G�(� as described in the application for
Disposal System Construction Permit No. 06 '2 EV, dated c O r
Provided: Construction shall be completed within t�Jof the date of this er All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date F- 7 f% b Board of Health
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