HomeMy WebLinkAboutApp-Permit-ComplianceNo.✓� FEE J
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COMMONWEALT14 Of MASSACHUSETTS
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Board of Health, to QaM U, -)M6 , MA. j
APPLICATION FOP DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairXUpgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location ` jv
M Av f L o w ee
Owner's Name `Dn,QN� iN4 &i(,
Map/Parcel# 30144
Address S ,
Lot#
Telephone#
Installer's Name
Designer's Name J Yl
Address
� � f
Address M
Telephone#i
b
Telephone# —
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures tC1Le,r
Design Flow (min. required) gpd Calculated design flow
Plan: Date 't 16 Zl S Number of sheets t
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Lot Size 6 sq. ft.
Garbage grinder (P� j
No. of persons 1-9-, Showers (Cafeteria (
DESCRIPTION OF REPAIRS OR ALTERATIONS -1PP�` C -\,t23 ,6\ 0,-.\
Design flow provided gpd
inion Date
Date of Evaluation
The anjdrsigne d agrees to install the above describedIndividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthere to of to place tem in ration until a Certificateo Co apliance has been issued by the Board of Health.
Signed Date J
Inspections
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No. U _ FEE_
COMMONWEALTH OF MASSAC14USETTS
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Board o Health, ,
CERTIFICATE OF COMPLIANCE � l�°t��t s ��� In
Description of Work:] Individual Component(s) ❑ Complete System 7
The undersigneereby certify thate Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded, Abandoned ( )
by: ,lL C > �k
at V
has been installed in accordance with the provisions of 310 CMR 1 .00 (Title 5) and thea proved design plans/as-built plans relating to
applicati4N. _.- % da — �s . Approved Design Flow (gpd)
InstallerDesignerGl./ Z /!G`1GC %, Inspector: Date:
The issuance of this permit shall not be construed as a guaranEee t the sysien will function as designed.
No.
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COMMONWEALT14 OF MASSACHUSETTS f -7
Board of Health, MA.
DISPOSAL. SYSTE CONSTRUCTION PERMIT If O V
Permission is hereby granted to; Construct( ) Repair( )
at
ek") Abandon(
an individual `sewage disposal system
G as described in the application for
Disposal System Construction Per.l No. d ! h , dated ?
Provided: Construction stall be completed withins of the date of this it` All local conditio must be met.
Form 1255 Rev. 5/96 A. .. SuWn Co Boston, MA i / Date '� - Board of Health J %