HomeMy WebLinkAboutApp-Permit-ComplianceNo. o y -1)C -LG -(t4 03
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19 a COMMONWEALTH OF MASSACHUSETTS
Board of Health, )A.OL+ tq- , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑
RECEIVED
OCC 042019
ERMIT
HEALTH DEPT.
lividual Components
Location .30
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1 Owner's Name
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Map/Parcel#
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Address 3G /1t� S.
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Lot#
Telephone# S4?
Installer's Name/=�
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Designer's Name
Address a
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Address --'
Telephone#
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Telephone#
Type of Building Lot Size sq. ft.
Dwelling -No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
gpd Calculated design flow
Number of sheets
Design flow provided gpd
Revision Date
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersigned agrees in tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no a to o r until a Certificate of Compliance has been issued by the Board of Health.
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Signed i Date
Inspections
No l.aCi 4•r �?C� O lq t' C_° FEE q,�, t (..d,�
� COMMONWEALTH OF MASSACHUSETTS ._.,'lad ?i �:J-
s i y� d ik ho Board of Health, YAtA2,M0f.)T 14MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that die Sewage Disposal System; Constructed ( ), Repairedd�\_Upgraded ( ),Abandoned ( )
by: 1';M',
r
at a,,'y`�"'�k „ .,`r�`y "� l,�oA•zA'rP"= +"(E5
has been installed in accordance with the usm s,of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ''°° c dated>' '" d t' . Approved Design Flow ..^"" (gpd)
a
Installer f. t',
Designer: ""` Inspector tI n �J �.:t t°`l f.=� �^ .tom .� Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.N o. d
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9 C9 0 ° _ COMMON LTII OF ff MASSACHUSETTS
fl Board of Health, YOi_98'�'.3()'r MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair,(,N)Upgrade( ) Abandon( ) anindividual sewage disposal system
4
at (� t �',v rf. `� �' �° r ^, �'`!l as described in the application For
Disposal System Construction Permit No. )`1-� ��.�'-- ,dated r�
y�1
Provided: Construction shall be completed within three years of the date of this ,permit. All local conditions must be met.
Porn 1255 Rev. 6/96 A.M. Sultrin Co. Chatlesarn,MA Date
I%/�! (r Board of Health 5 ( ��