HomeMy WebLinkAboutApp-Permit-ComplianceNo. Bot�a�—1301 7-t/ FEE 4Ar00
►R — 1280 COMMONWEALTH OF MASSACHUSETTS c>��7�� r7��
r 1�Ol E t - 'U\ Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(,/ Repair( ) Upgrade( ) Abandon( ) - 'H/Complete System ❑ Individual Components
Location ry' -
Owner's Name 77
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Map/Parcel#
Address
Lot#
Telephone#
Installer's Name fLa
Designer's Name
Address ` •
Address ,.",:g;
Telephone# U' 5,1 Z
Telephone# ": '7�C`_,
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Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) .3 /�' 6 " gpd Calculated design flow Design flow provided 33"0 gpd
Plan: Date /Q 7 " / �i+ Number of sheets I Revision Date
Title
Description of Soil (s) -S :� 4 , e'A
Soil Evaluator Form No. Name of Soil Evaluator ltl , Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS n�, / / `�✓ ��
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 p ace the m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �'/ �` Date
Inspections
tP4 a.. `, �.► .. 30 FEE 0' /10, 06
No »+" 4;
COMMON LTH OF MASSACHUSETTS'
BoardofHealth, `,h-,i-amok,ni -, MA. NE';�Ds1
CERTIFICATE OF COMPLIANCE A$'$UfLT
Description of Work: ❑ Individual Component(s) ElComplete System q,! } -
The undersigned hereby cef tify that the Sewage Disposal,System; Constructed ("�.QRepaired ( ), Upgraded ( ), Abandoned ( )
by:at
,G%'r..J..S"a`,r'"�` g, ..S ,q=',';7;s 4• °"�'°rru."g`.,or
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has been installed in accordance with the provi ions pf, 10 CMRR115.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. dated .%�A fir'' .'�°µ Apprbt'ed Design Flow "> > e`.3 (gpd)
Installer
Designer: .h;�a <' ea�Y �P.e,^ l_. Inspector.'� ) ,lr` Date:—,,
The issuance of this permit shall not be construed as a guarantee that -the systemwill-function as designed.
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.m_c ' COMMONWEALTH�p OF MASSACHUSETTS
Board of Health, 'YAwwk MA.
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DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;
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Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
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.
1 a
Form 1255 Rev. 5/96 AM. Sulkin Co. ChaIkAOWn, MA Date i8 $�
) �' � `,N Board of Health t-') � .�