HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,gpy-�c-L��bNI'7 FEE S��t7b
ON ITS COMMONWEALTH Of MASSACHUSETTS Ck,*(ILI-73
Board (!f Health, Y =M0jM , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct.( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System 0Individual Components
Location
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Owner's Nam'
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Map/Parcel#
Address
Lot#
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Telephone#
Installer's Name
Board o Healdlo,
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Designer's Name
Address""�
CERTIFICATE OF COMPLIANCE
Address
Telephone
Description of Work: O Individual
Telephone# -
Type of Building , A I 1
Dwelling - No. of Bedrooms.
Other - Type of Building _
OtherFixtures
Design Flow (min. required)
Plan: Date
Title TC
Description ofSoil (s) I
Soil Evaluator Form filo.
gpd Calculated design flow
Ser of sheets
Name of Soil
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided i^, / 1 V gpd
Revision Date
of Evaluation
The undersigned agrees to install the above described Individual Sewage Disfigsal Sy tem in accordance with the provisions of TITLE 5 and
further agrees to not to�,^plyce the system in operation until a Certificate of C rhpIi �e has been issued by the Board of Health.
Signed I _A�� (�i�..) y Date
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Inspections ill ki l �4 V®
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No.
COMMONWEALTH OF MASSACHUS1ETTSot=�`�
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Board o Healdlo,
l A1ZMWn+ MA.
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CERTIFICATE OF COMPLIANCE
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Description of Work: O Individual
Component(s) C].Complete System
The undersi=ted hereby.ce tfy thatthe Sewage Disposal System psu acted ( ), Repaired ( )., Upgradedlr' ,"Abandoned
( )
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has been installed in accordance with the.prv slop • gf 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No + """` tl) dated a ""`dt�4 Approved Design Flow d
Installer -ti'" (� r( i / A'\ �'YF i ¢ ''1."' d `� 1° �,y bUTA.)( t.i.-, ,
Designer. f: �"`C� } --D 9" +' L J-4) Inspector: roe, 6< VVII Date: `.'"s✓`"t"'� r�� a t"
The issuance of this permit shall not be construed as a guarantee drat the system will function as designed.
No. r"' C)'` ' (° ,� � t"7-" 1 ( V" }C.�..m FEC ,. e f'a 2 U)
COMMONWEALTH OF MASSACHUSETTS
Board of Health, VA-ai ? t} m MA. 7
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DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;, Construct( ) Repair( ) Upgrade(v) Abandon( ) an individual sewage disposal system
tt r_
at ,-P as described in the application for
Disposal System Construction Permit No. `` t datt:dGil T
Provided: Construction shall be completed iyithin three years of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Suakin Co. Chsdeslmvn,M1N 1)ate±�a° R �'n$° � � Board Of 1-ie21t11
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