HomeMy WebLinkAboutApp-Permit-ComplianceNom: FEEb` 00
COMMONWEALTH LTH OF M SSA � U* SETTS
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Board of Health, `((+R hill of MA. IKKROWIDD i
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PER IT APR 10 2999
Application fora Permit to Construct( ) Repair+,/Upgrade�bandon( ) ❑ Complete System ldlndividu t
:Co M OUT
Location
6 Pi ✓i P/
Owner's Name l j 6►
Map/Parcel#
Address
Lot# 9
AA p^ r !
Telephone#F
Installer's Name
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Designer's Name o
Address
y /L
�7C&v4
I f Address
Telephone#
Nab -01
2
Telephone#
Type .of BuildingLot Size sq. ft
Dwelling.- No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers (' ), Cafeteria
Other Fixtures
Design Flow (min. required) SSL -2 gpd Calculated design flow Design flow pprrov'ded 5W gpd
Plan: Date `Y / 9 Number of sheets _ % Revision Date
Title
Description of Soils) %e�
Soil Evaluator Form No. __ Name of Soil EvaluatorT JW Q L Date of Evaluation
DESCRIPTION OF REPAIRS
The undersigned.agrees to install the above described Individual. Sewage.Disposal System in accordance with the provisions of TITLE 5 and
further agrees to notjo place the: system, in operation until a Certificate.* of Compliance has been issued by the Board of Health.
Signed %/�V �'' Date
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Board of Health; MA.
CERTIFICATE OF ��'I�LII� TC
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+� Desci-><ption of W`rk: OfInifiVA4ual Component(s) ❑Complete System � , �j( `�� .��•�
The under" ed hereby•certify tha thejSewage Disposal System; C nstr icted ( ), Repaired ( ), Upgraded 7K13andoned ( ).
_
t is r, has been lrtstalleth,7rz ccordance with the rovisions of 3 O CMR 15.00 (Title 5) and the ap oved design plans/as-built plans relating to
application No. f dated / . Approved Design Flow (g d)
Installer M
'esigner: y►; "A. #: lit; i �}ector: P #."-' Date ,t�
„The issuance of this permit shall riot be constrq aas arantee that the system will fu ctzon as desi ed +
No. G o o s 1~= Tn FEE
-XCOMMONWEALTH Of MASSACHUSETTS
^y
Board of Health, Y am U74 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;: Construct( ) Repair( ) Upgrade (,—)--Abandon (` ) an individual sewage disposal system
s/ as described in the application. for
Disposal System Construction Permit No. Lam; dated
Provided: Construction shall` be. completed within tkrreemar�the date of this per All local co: di ' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChadeetownNA Date ! Y,iC ��I / Board of Health