HomeMy WebLinkAboutApp-Permit-ComplianceNo. Iy H'YC/ r I OLD -20-N37135 FEE t5_�5',
D f LSAS 0lQ --\1 COMMONWEALTH OF MASSACHUSETTS uam-1
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9,ODBoard ofHealth, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION R RMIX o �� 2Q20
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑ Indwidual Comporients:,
LocationIx
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Owner's Name
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Map/Parcel#
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Address
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Lot#
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Telephone#
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Installer's Name
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Designer's Name �(A)f
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Address
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Address R)
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Telephone#
O�'`�''� (�' �)
Telephone#
Type of Building C �c
Dwelling -No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size a sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
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Design Flow (min. /required) .33 p gpd Calculated design flow Design flow provided _� gpd
Plan: Date (,� La' tell Number of sheets Revision Date
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Title
Description ofSoil (s) _
Soil Evaluator Form No
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1LA \ N w -Pbc) 1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
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'Signed
�..- _-/'—"�-�.- Date
Inspections
No 0..✓C�): AC. w-d),..-(..1t..i ' FEE
L' C' 1 2- COMMONWEALTH OF MASSACHUSETTS'
Board of Health,MA.
CERTIFICATE OF COMPLIANCE
Description of Work: l] Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (Abandoned ( )
by:
i
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . Approved Design Flow `' ( (gpd)
p
Installer
Designer: - t" t < f Inspector: CR t� Date: i d i- }
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No Y;alj(.).1,�( pm=,.'-V�l 1%_C-r_/(-..i'i FEE,`-��'a L)d 1
COMMONWEALTH Of MASSACHUSETTS
Board of Health, "18A-d"l ,118.5 d 11 i- MA.
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (- �f Abandon ( ) an individual sewage disposal system
at 3 " i "i as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within three ,years of the date of this permit. All local conditions must be met.
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Form 1255 Rev. SM A.M. SUINin Go. Chatleslvxn,MA Date 1 �� rt L � i. Board of Health l i 9� �Ft t .!�t er