HomeMy WebLinkAboutApp-Permit-ComplianceNo. �Y'� F/� /� �/'� FEE ifJO
2O COMMONWEALTH OF MASSACHUSETTS o�
Board of Health,, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUC -0 FPERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Locationt..�
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Owner's Name �o`L l
Map/Parcel#
�� ��a 3S
Address
Lot#
Telephone#
Installer's Name
/ C, /
Designer's Name --r'
Address
Address
Telephone#
C:% G%- J
Telephone#
Type of Building _ / W_1>
Dwelling -No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OI; REPAIRS
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No. of persons
Lot Size
sq. ft,
_ Garbage grinder( )
Showers ( ), Cafeteria ( )
_gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above descn ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees o I the system in ope tion nn ' Certificate of Co pBance Pas been issued by the Board of Health.
Signed !�G Date 2
No. "'1.. "79 t�„� FEE
COMMONWEALTH OF MASSACHUSETTS'
Board of Health, MA
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CERTIFICATE �OF COMPLIANCE )
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby ceryly that the Sewage Disposal System Constructed ( ), Repaired q(4fQUpgraded O, Abandoned ( )
at.ABI 1,
has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No'' dated 1 `�B 1 a t'.-: Approved Design Flow '" (gpd)
Installer ° ,i' R--'xa'^' Inspector: ✓ pp ,eg Date: ° ",
Designer: gk
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. e 1
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No. „d -1 .y kip,. "' d�-4. } i „:.{r'1"}„. €;"" '�'�dG'., y i°!^ FEE"-".i�^t,..
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( COMMONWEALTH Of MASSACHUSETTS)?fF
Board of Health, x' i'j'Io1:?:4 MA )P B, aJL
DISPOSAL SYSTEM CONSTRUCTION PERMIT-"
Permission is hereby granted to; Construct( ) Repaid--)Repaid--)Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. 4 I , 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. 5/98 A.M. Sulkln Co. ChaheW, MA Date ij irl 1l4:1L Board of Healthti
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