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HomeMy WebLinkAbout24-13G 1'9L ,C� FEE o COMMONWEALTH OF MASSACIIUSETTS t" Board r f Health, , MA, b� APPLICATION FOR DISPOSAL YSTYM CONSTRUCTION PERMIT Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location ATIA)d Imfier's Name Map, Parcel# y Address itid Lot# Telephone# Installer's Name Designer's Name Address Address Z Telephone# _ Telephone# _ Type of Building t�rn rlo _ Lot Size Dwelling - No. of Bedrooms _A.e� Other -Type of Building Other Fixtures Design Flow (min. re uired) Plan: Date Title Description of Soil(s) i Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator No. of persons sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided M),N gpd Recision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The un ees to install the afinoperation described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 further agr s to no o place t until a Certificate of p ' ce has been issued by the Board of Health. Signed Date7 03 Inspections VL du No. DAL 2� COMMONWEALTH OF MASSACHUSETTS Board of Health, Alc\, MA. CIRTIFICAA OF COMPLIANCY Otl FE) Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed k,), Repaired ( ), Upgraded { by: at 5c� � ), Abandoned( } has been installed in accordance with the prodsions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.,2(J b 7 u , dated _t_3 j -a c/ . Approved Design Flow _(gpd) Installer PM r zb4d L ,[ 4x- - Designer: �„ C . Inspector: �, Date: //�►� 1' P41 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. (1 111J N: FEE _ COMMONW"LTII OF MASSACHUSETTS Board (f Health, -) A-•' 12�— MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to ConstructO Repair( Upgrade( ) Abandon( - © Complete System O Individual Components Location -- Owner's Name — — L Map/Parcel# Address Lot# j Installer's Name Telephone#;/ / . - Designer's { �—Address Name F Telephone# Address { > t/ — -- _ -- Telephone# Type of Building Dwelling - No. of Bedrooms _ Lot Size sq. ft. ' Other - Type of Building _ Garbage grinder ( ) Other Fixtures No. of•pelsons Showers ( }, Cafeteria ( ) Design Flow (min. required) Plan: Date gpd Calculated design flow g Design flow provided �, gpd — Title Number of sheets Recision Date Descripuon ofSoil(s) Soil Evaluator Form No. Name of Soil Evaluator bate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undWigne_d 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 Compl' ce has been issued by the Board of Health. Signed _ Date 7 Inspections No. ;.�, , . ,.___� nt 6(1 COMMONWEALTII OL MSS�ICIIUS�TTSr} ' / �t� FF.T � - �.,: Board of Health, CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) 0 Complete System The undersigned hereby certify that the P Y Constructed System; e Disposal osal S (,Repaired ( ), Upgraded ( ),Abandoned O~` by: at has been installed in accordance with the provij sions of 310 CMR I5.00 (Title 5) and the approved design plans'as-built plans relating to application No. dated, . Approved Design Flow Installer -� r749 w L A", --(gpd) Designer: t . —'� - Inspector: *'-«--�- � . � � _Date: 1t. The issuance of this permit shall not be construed as a guarantee that the system will function as designed., No. -.ti- r COMMON"A�LTLI OF :Elect",Le M�4SS�4LIIUSETTS a,.,,, 4 Board of Health, _ -•n tK2 Nm-As r! t^ t DISPOSAL SYSTEM CONSTRUCTION PERMIT C9r-� ip 1 4cc rne,-sRQ Permission is hereby granted to; Construct( } Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at ` a i� du as — as described in the application for Disposal System Construction Permit No, )t / �', ; _ dated _ Provided: Construction shall be completed within three years of the date of-thispVnnit. All local conditions must be met. Form 1255 Rev 5/96 A.M. Sulkin Co. Chadestam,MA Date -- Board of Health a: A O O Q p `r f0 O O O •� C G < Cl cn CD 00 CL O i G CD LA -1 e C a- cn %� � o ij 0,, ye�ms-�+r _� e M a � . 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