HomeMy WebLinkAboutApp-Permit-ComplianceNo. c/o�kyC-Iq—O� /3 FEE ( 6
COMMONWEALTH OF MASSACHUSETTS c,666Z
Board of Health, YAQM0V- !' , MA. ll ` b X G✓t�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ) R�r( ) Upgrade( ) Abandon( - ❑ Complete System. dual Components
location O le'
Owner's Name �,,,,.' ✓✓
Map/Parceltk
Address
Look
Telephone#
Installer's Name ke-- �
Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building /t,'r4— h / Lot Size
Dwelling - No. of Bedrooms
Other -Type of Building No. of persons
Other Fixtures
Design Flow (ruin. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
gird Cafculated design flow
ber of sheets _
Name of Soil Evaluator
146G
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
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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 C mp ' mce has been issued by the Board of Health.
Signed Date A)1 ei
Inspections
No 4't t -f "(it f `% ✓� Y j3.! r. a^,y ' FCL v ',,"`?n._.
F C®MMONWEALT14 OF MASSACHUShT�S
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Board of Health, V 470110 ))14- , MA. � ,a
CERTIFICATE OF COMPLIANCE
Description of Work: f�-Individual Component(s) ❑ Complete System Iya / i (vje7-,; tr1✓'` �� f
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and dig a proved design plans/as-built plans relating to
application No.
t 1 „I -cA XO—, dated ) B^ . 9 J . Approved Design Flow.,f..r /t (gpd)
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Installer ,� p
Designer: j'"�•',�%' Inspector: N', a sF,<f%z >^".�.a��' Date:
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:The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.-¢�•1C"� T't}ff,. ��I t� FEEi�.l-7 -t1'
COMMONWEALTH OF NiASsACMUSETT'S
Board of Health, iLs.-tLoejn, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT b /
Permission is herebygranted to; Construct( p)' Repay ) Upgrade( ) Abandon( ) an individual sewage disposal system
at C f r'r - P as described in the application for
7
Disposal System Construction Permit No. Ci-- 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. 5196 A.M. Snikin Co. CloeestaNn, MA Date 10 d5'T 13oard of Health
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