HomeMy WebLinkAboutApp-Permit-ComplianceNo. 66%'DC 4 —0320 FEE'. 653 700
COMMONWEALTH OF MASSACHUSETTS
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W� Board ofHealth, 7 Nil �.l (7 4 , MAFOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to .Construct( )'Repair( -) Upgrade(�andon() - ❑ Complete System E'Tindividual Components
Location39 I ► ` v �i -
Owner's Name
Map/Parcel#
Address
Lot#
Telephone# 7 7 tJ_ / yc'
Installer's NameDesigner's'Name
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Address
ress /'��.
G a r
Telephone# S g —77(i 'li �/
Telephone# r -o _ 31ot
Type.of Building /�/f►'4�`�1k Lot Size sq. ft
Dwelling - No. of Bedrooms �c9&A� Garbage grinder
Other - Type of Building _ No. of persons Showers (' ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow ) Design flow provided gpd
Plan: Date r` 1V a d/T_ Number of sheets _ Revision Date
Title
Description ,of Soil (s)
Soil Evaluator Form No. —
Name, of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
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 the system in operation until a Certificate of Coy pliance has been issued by the Board of Health.
Signed Date
T1
'No.—
COMMONWEALTH
o.C®MMON LTH OF MASSACHUSETTS.,
,- Board of Health, !41 M007f MA.
FEE ""' Q
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CERTIFICATE Of COMPLIANIC E /K
Description of Work: dual Component(s) ❑ Complete System Cj f-`✓'�'Errj
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ); Repaired { ), Upgraded ( bandoned O /
at
has been installed in accordance with the provisions of 0 CMR 15.00 (Title 5) and the ;approved design plans/as-built plans relating to
application No. ` �7 ,dated, ^� /' . Approved Design Flow V410 (gpd)
Installer 41
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Designer: _ U415 R--6— IPA C •+P� inspector: �' Date:
The issuance of this permit shall not be construed as a guarantee that the system. will function as designed.
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No. o -V 1!�. 1 ,
7 COMMONWEALT14 Of MASSACHUSETTS
FEE '
4
Board of Health, YA"OUT-* , M.A.
DISPOSAL SYSTEM[ CONSTRUCTIONARMIT
Permission is hereby granted to;: Construct( ) Repair( ) Upgrade( Abandon ( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No: P t —K7 / , dated
{ � p. �j ditlions must be met:
Provided: Construction shall be completed wit xx th re�,.y, of the: date of this. � x Ail��� /c�i1 J
Form 1255 Rev. 5/96 A.M. Sulk1n Co. Chadestown,MA Date — �� — Board of Health (/ ���