HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 116jp=M0(rri+ , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct.( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System IJ Individual Components
Location i
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Ro
Owner's Name Fes( f+, l �^' j/� LRv (-o
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name0
, }C`=�'" r Co , Tl)(.Desig'ner's
Name �-----�
Address
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t-bUlf��a
Address
Telephone#
elephone#
Type of Building _ Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils) _
Soil Evaluator Form No.
gpd Catculated design flow
Number of sheets
Name of Soil Evaluator
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS ORAITERATIONSi �� �, �.a C*r?. > � 4 ° <)L i2,) (Z"z�p r
E i icy
rower �v�So env 1,t 7z-�) j-=vc,k-F 5.cf1),-Nc sir
The undersigned agrees to inf=1
above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to plpop�enation until a Certificate of Com lian)ce yh'as been issued by the Board of Health.
Signed Date �/-t�t�
Inspections
k
No i l FEE
y COMMONWEALTH OF MASSACHUSETTS
Board gfHealth, 'f' S 6t1`1-7: Mfl. [j f
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) ❑ Complete System
t,
The undersigned hereby certify that the. Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded O, Abandoned ( )
by: I�, 01,-, , c..w,,..a � fir} t"'+"".»
at )°� �� "�o C,I"\Ir-%t? - 0 fA,
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)
Installer W ("z C jk)(L k
Designer: Inspector: 4 (.g.. °'..."' Date:
z,
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
Permission is hereby
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COM ONWEALTH OF MASSACHUSETTS
Board ofHeallh, gL2MO $I ", MA.
DISPOSAL SYSTI;t�'[i CONSTRUCTION PERMIT
to; Construct( ) Repair( ) Upgrade( ) Abandon(
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N
9 lP rs
FEE
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an individual sewage/dtspasal system
_ as described in the application for
Disposal System Construcuon Petmtt o. . ate rte_
Provided: Construction shall be completed within three years of the date of this permit. All local conditions Hurst be met. '
Form 1255. Bev, 5196 A.M. amkin co. Cl6Ae9m, MA Date °•'. .m le- Board of Health