HomeMy WebLinkAboutApp-Permit-ComplianceNo. d FEE �
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Board of Health, 11 f''�,, R0k3TEE 2S , MA
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
plication for a Permit to Construct( ) Repair(. Upgrade( ) Abandon( ) - Er/Complete System ❑ Individual Components
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ocation
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Owner's Name
ap/Parcel#
Address
Lot#
Telephone#
Installer's Name �`
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Designer's Name V&I
Address
Address
Telephone#
Telephone#
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Type of Building le 5% e er if Lot Size sq. ft.
Dwelling - No. of Bedrooms 13 Garbage grinder.(4*/o
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures yy f
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date %�Z/��% Q `j Number of sheets Revision Date
Title dr `v/-�Ola� 4!— �(��/�" lam/ 4'/' �•9.
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to ace a em in operation until a Certificate of Compliancq has been issued by the Board of Health.
Signed Date �-
No. 4 11 IF—EE 1411
COMMONWEALTH OF MASSACHUSET
Board of Health, r��y-�
, MA. -
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned herebyy certity that the wage Disposal System; Constructed ( ), Repaired (A'< Upgraded ( ), Abandoned ( )
by: A��I'X27
at .r�451t )1 GCS 4I'r �% /
has been installed' acc ante with the rot' ion g€ 310 CMR 15.00 (Title 5) and th approved design plans/as-built plans relating to
application No.,, wed td . Approved Design Flow (gpd)
Installer
Designer: LhiG Inspector: / Date:
The issuance of this permit shall not be construed as a guarantee t at the system will function as designed.
No -0
Board of Health, ,/ er rWK�7 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted t ; Construct( ) Repair(K Upgrade( ) Abandon( ) an individual sewage disposal system
at f 1�(I //--Gf%k47/, -/- " /d,
as described in the application for
Disposal System Construction Permit No. , dated — _. { (o .
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Provided: Construction shall be completed withi�"rs of the date ofi permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkiyn'Co. Boston, MA Date � �/�� Board of Health , 'ti..�
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