HomeMy WebLinkAboutApp-Permit-ComplianceNo: w�� C �l -3Z�3 G� L_V'V(L - I9 - Uv�(oT1 FEE 66_
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COMMONWEALTH 166 MASSACHUSETTS R�� I
Board of Health, VaZM MA. MAYS 2 3-2 0 9
APPLICATION .FOR DISPOSAL SYSTEM CONSTRICTION P MjtLTH DEPT.
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ❑ Complete Systei vidual Components
Location/-
Owner`s Name
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Map/Parcel# - T& 7
Address 3 6 }+(n
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Lot#
Telephone# 9,6o "
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Installer's Name f� -f
Designer's Name lo
Address
Address
Telephone#���— ller
Te lephor4f# °� T ..
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Type of Buildingof Size 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 provided gpd
Plan: Date ,'S ;Z,j (�j Number of sheets _ Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. — Name of Soil Evaluator a/ eavate of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS / t zo CL - bo x.?, / 11 ZD 5 ao ch—e""& _S
The undersigned agrees to install the above described Individual Sewage Disposal System.in accordance with the provisions. of TITLE 5 and
further agree of place the s m m o ation until a Certificate of Compliance has been issued by the Board of Health:
Signed, - Date ala
j'
Inspections
No. u r c- 19 32-3-5 � �f EE
COMONWEALT OF MASSACHUSETTS �
Board of Health, , MA.
CERTIFICA E Off' COMPLIANCE o�
Description.of Work: Individual Component(s) ❑ Complete System
The undersign d hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned
been installed in ac(
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Installer K_
Designer:
The issuance of
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With the rovisions o 10 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
�d.,ated ' /.� . Approved Design Flow (gpd)
J`=
Inspector:
Date:. tV �
not be construed as a guaraee that the system will function as designed.
No.-��_"iCJ"��s�HZ
COMMONWEALTH Of MASSACHUSETTS 80YO
Board of Health, AIA
DISPOSAL S•YST . CONSTRUCTION PERMIT
Permission is hereby granted to;; Construct( ) Repair( ) Upgrade (< Abandon( ( ) an individuttl sewage disposal system
at /1\l �a�'' , ` as described in the application for
Disposal System .Construction Permit No. dated`) -/�
Provided: Construction shall be completed within t e; date of this per . it. All local cond. 'ons must be met.
' Bo
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Form 1255 Rev. 5/96: A.M. Sulkin Co. Chadestown, MA Date . 12
,/ ard of Health