HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0VVD' ZaA2- ! FEE ��
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 1)TH , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name
Map/Parc
Address
Lot#
Telephone#
Installer's Namecla
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Designer's Name
Address
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Address
Telephone#
Sb -)
Telephone#
Type of Buildingyj cS: 61M (0 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
Revision Date
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS
gpd
e undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
rther afire/e to/ngt\place the system in operation until a Certificate of (Compliance has been issued by the Board of Health.
Signed / / \ /��_ Date ^ t 1
Inspections
COMMONWEALTH OF MASSACHUSETTS"
Board of Health, A-9Da}`a"+ MA
CERTIFICATE OF COMPLIANCE
FEE
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Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that die Sewage Disposal System; Constructed ( ), Repaired O, Upgraded O, AbandonedI'll ( )
by.
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)
Installer
Designer: / Inspector �h. ��'?"�... /`e" t ^__.-,..!✓" Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 4"")oAV -Z-0-4JLd4`'t:;••. FEE °t, ., t
COMMONWEALTH LTH ®F MASSACHUSETTS
Board of Health, AnG,Mdit )"M- MA. ,
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Permission is herebygranted to; Construct( ) Repair(i) Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev, 5196 A.M. Sulkin Co. Chatlesoxn, MA Date d '.;''w;^F✓ Board of Health
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