HomeMy WebLinkAboutApp-Permit-ComplianceNo. V� t4DG" 19-0779 � �~ � _ FEE'
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COMMONWEALTH Of MASSACHUSETTS
r -7V? -c Bon)d of Health, 1AkMDQ MA.
e-,�'�eeZPPlLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(.) Upgrade,�bandon( ) - ompiete System 1] Individual Components
Location 97. kuOwner's
Name
Map/Parcel# 33
Address''
Lot#11
Telephone#
Installer's Name
Designer's Name
Addressa)N
Address aO� eau
Telephone# - — I
Teleq;lphone* - r
Type of Building Y27&Le- Lot Size :91 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder(
Other - Type of Building No. of persons Showers ( ),'Cafeteria { )
Other Fixtures
Design Flow (min., required) gpd Calculated design flow �� Design flow provide
Plan: Date I ' J 8r Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the, provisions of TITLE 5 and
further afire to place tem in operation until a Certificate of C mpli nce has been issued by the Board of Health..
Signed ..r /` Date
s
No. w'tic
Board of Health, 1'k(Z,-�00q , MA. f
CERTIFICATE OF COMP LANCE.,� LL,
Description of Work: ❑ Individual Component(s)Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired , Upgraded ( ), Abandoned ( )'
by:
has been installed in accordancewith the provisions 4,310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. tf dated f l) '- /�k" . ApprovedDesign Flow _(gpd)
Installer
Designer: ' Inspector: i'" Dater
The issuance of this permit; shall not a construed as a guara ee that the system will function as designed.
No. b t) tk
D .. C 1 -29y FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, �Y1 �it 0 , Nm-
DISPOSAL
A.DISPOS L SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ) Upgrade ((� ) Abandon ( ) an individual sewage disposal system
at �e�W_ )C2, Q _ .%d;�rinn tX.-N eN as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within -4 � s Z date of this peri - it.�All local condi ons must be met.
Form 1255 Rev. 5196 A M Sulkin Co. ChadeSlown, MA Date %, Board Of Health / t
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