HomeMy WebLinkAboutApp-Permit-ComplianceNo.- -TV-1r"
COMMONWEALTH A LTH ®f MASSACHUSETTS
Board of Health, , MA.
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APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location ? i
Owner's Name
Map/Parcel#
Address t QCT.
Lot#
Telephone# ,.
Installer's Name
Designer's Name Ca ge, CN q iAn4Pe4_"
Address
Address
Telephone# -
Telephone# _.36 -
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS _AQ y -e _ se.0)4 C. M (/� ► S� a:(
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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 afire of to place the system in operation until a Certificate of Comphce has been issued by the Board of Health.
Signed Date
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Inspections
No. 1 .3 � FEEy
COMMONWEAOF MASSACHUSETTS Pf
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Board o ea�tli' MA.`
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CERTIFICATE Of C®MPLIAN E
Description of Work: Individual Component(s) Ll Complete System / iC-e
The undersigned here/by certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ) , Abandoned (VQ `
by:
OF _j- oq 'c'k,
at `
has been installed in accor
application No. � _
Installer t
dance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
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Designer: 1ZI LNA k-02 ` ICC Inspector: P_11" Date: 4
The issuance of this permit shall not be construe as a guarantee that the system will function as designed. e+
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No. r ��
®MM®N�LT OF MASSUSI
Board T Health, A-4 It, U'i _, MA. S= �t C_ rt�
DISPOSAL SYSTEM CONSTRUCTIONPERMIT (" A C/
Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
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Disposal System Construction Permit No. �� , dated S
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date ��- / Board of HealthAt3 k -'