HomeMy WebLinkAboutApp-Permit-ComplianceNo. ✓C� L j �Z FEE,��
COMMONWEALTH Of MASSACHUSETTS
Board of Health, 1 �i -1CM 0LAA—V1 1 , MA.
. PPLICATION FOR
`DISPOS L SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair()() Upgrade( ) Abandon( ) ❑ Complete System Adividual Components
Location
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Map/Parcel#
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Address S
Lot#
Telephone#
Installer's Name 9a - r- f -f AC6u A
Designer's Name
Address ( 7
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1V0--- *J10k A/1 -(>4445 0-3(49Address
Telephone#
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Telephone#
Type of Building' !�� R '� C Lot Size sq. ft.
Dwelling- No. of Bedrooms �� Garbage grinder.(
Otlier-Type of Building No. of persons Showers (' ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan;Date Number of sheets Revision Date
Title
Description of Soil (s),
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
OF REPAIRS ORAL TERATIONS
The: undersigned agrees to install the above described Individual Se.wage.Disposal System in accordance with the provisions. of TITLE 5 and;
further agrees t of to PI e: ope on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
HEALTH DEPT.
C®O V�V� EALTjtJt .0F MASSACHUSETTS FEF
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( / Board of Health,"��k� i�t01}`�}i , MA.
CERTIFICATE OF COMPLIANC
Description of Work: individual Component(s) ❑ Complete System J/
The undersigned hereby certify t at the Se ge Disposal System; Constructed ( ); Repaired ), Upgraded/( ) Abandoned ( ).
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has been installed with the proVisions of 3 0 CMR 15.00 (Title 5) and the approved; design plans/as-built plans relating to
application No6ybl{75C"J�}•'i'�i c%ted Approved Design Flow (gpd)
Installer ac-: ``~sem 14- ( tQ S —
Designer: 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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COMMONWEALTH ®r MASSACHUSETTS t...1FA 712J
11 / Board of Health, )1A amo u -n4- ; MA.
DISPOSAL SYSTEM STEM CONSTRU'1::TIO - PERMIT
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) an individual:sewage'disposal system
Disposal System Construction Permit No
dated %�-
as described in the application for
Provided: Construction shall be completed w thiii'tl ree years of the date of this permit. All local onditions must be met.
Form 1255 Rev. 5/96; A.M. Sulkln Co. Chadestown, MA Date"'' f Board of Health