HomeMy WebLinkAboutApp-Permit-ComplianceNo. ��`/ o 114i3ist ,010`0 E'23�. a� ... �. .. FEE J t1.00. `i o``ti1'6di3 Ls U 1-1, PAA 02664
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgradekj Abandon( ) - A Complete System ❑ Individual Components
Location
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Owner's Name
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Map/Parcel#
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Address
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Lot#
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Telephone#
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Installer's Name �^ ` d�28 S
Designer's Name
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Address On
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Address
Telephone#
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Telephone#
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Type of Building II G s , —1 --2 Z ! C+ i Lot Size L o� b s2 sq. ft.
Dwelling - No. of Bedrooms 4-- APo Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 4 `F d gpd Calculated design flow 4 Design flow provided gpd
Plan: Date I of Sl 9 Number of sheets / Revision Date
TitletpZ`a� e -7 /
Description of Soil(s) JP ;F- j7 y '' 3 '' L- • ^Y -s, Z 3 / Z o
Soil Evaluator Form No. Name of Soil Evaluator /Z+o S•V W (c %x Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to lace the systeem mmoo er tion until a Certificate of Compliance has been issued by the Board of Health.
Signed .<J�� �r�_`�//�L Date "' �/�
A 1 /
+`,Inspections
No. ��,, FEE
COMMONWEATTH OF MASSAC14 SETTS
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Description of Work: -':'Q Individual Component(s) * WComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (, Abandoned ( )
by:
at
e Y P w L.., o -„ r
has been installed in accordance with the pro 'swr s of 310 CMR 15.00 (Title 5) and the
application No. — dated Approved Design Flow -44
Installer
Designer: 4!� .— . S .5 A%= r--• T P Inspector:
The issuance of this permit shall not be construed as a guarantee that the system will funs
design plans/as-built plans relating to
Date:
as designed.