HomeMy WebLinkAboutApp-Permit-ComplianceNo. Q oc w/ C --1j63 7 FEE
COMMONWEALTH Of MASSACHUSETTS C�i.�r �►� t
Board of Health,�O�)ls�- MA.
APPLICATION FOP, � ®� L SYSTEM CONSTRUCTIOYl.di
RM IT
Application for a Permit to Construct( ) Repair=) Abandon( ) - ❑ Complete Systemvidual Components
Location 2
t -i0 C es
Ve
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
C l'C 00
Designer's Name
Address �,Q,
�� ��
Address
Telephone# 0 -
a --' 1 Z Z5
Telephone#
Type of Building
Dwelling - No. of Bedrooms,
Other Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils) _
Soil Evaluator Form No.
DESCRIPTION OF
The un
further
Signed
Inspections
OR
VC
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Nt
x".
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
irthe
�*era'tion
ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
syste until a Certificate of Compliance has been issued by the Board of Health.
Date 3— (�7�
COMMONWEALTH OF MASSACHUSETTS
FEE
Board of Health, .. YAg&0kM4 , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired , Upgraded O, Abandoned (/ )
by:
at Ave
has been installec?.�Qa clam ith1 ovisions of/310 CMR 15,00 (Title 5) and the approved design plans/as-built plans relating to
application No. _ Zo – � dated :::L IF -' . Approved Design Flow `— (gpd) f
Installer , ;�. (E' kk v of ! (6,oc 5� 6 r,
Designer: '� Inspector:_ � I ., � �_ Date:
The issuance of this permit shall not be construed as a gura6devthat the system will function as designed.
No. AC --90i37 X. -To %%C !NSP. FEE
I Ll
Board of Health,��.jZ&AQ , MA.
DISPOSAL SYSTEM STRUCTION PERMIT
Permission is hereby] ra t d to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at q- (- -)I -4 cr -ell ( Ve as described in the application for
Disposal System Construction Permit No. Y' dilated
Provided: Construction shall be com le' to wifK t6 e �e c f the date of this ermit. All local condiq' ns must be met.
P I/g S P �
Form 1255 Rev. 5(96 A.M. Sulkin Co. Chadestown, MA Date. t PioaiU Waith
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