HomeMy WebLinkAboutApp-Permit-Compliance2 C 6,577 FEE C`5 OO
No. 6�µQ� -I J-
Y 7k // COMMONWEALTH OF MASSACHUSETTS
Board of Health, �gMQ Uri' AL4•
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION P &.e4
n
Application for a Permit to Construct( ) Repair O Upgrade.AbandonO - XJ Ci inomplete System ❑ Individual Ca
Location 7
Map/Parcel# M 79 /d/
Owner's Name °
Address "
Lot#
Telephone# 3 70p—
Installer's Name 9�
Designer's Named
Address
Address 19a l4epe, G � &
Telephone#_�j��
Tee e# -� --
Type of Building ,J
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date Num
Title
Description of Soil (s) 101 _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERt IONS
The undersigned agrees to install the
further agues to not to place the sys
Signed —2a"e
Inspections
in
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided �'� gpd
Revision Date
Date of Evaluation
°
described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
ope 'on until a Certificate of Compliance has been issued by the Board of Health.
Date��/ /�yJ
No. � �.i� _ �S�J% FEE ' W-00
6--7? COMMONWEALT14®f MASSACHUSETTS ck-4 9-51-1
Board of Health, Y 0 UT -H , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (L)--bandoned ( )
by: 4�
Y—
at
has been installe in accor far c w e p 7o�isions o 310 CMR 15.00 (Title 5) and the a}�proved design plans/as-built plans relating to
application No. %S� --/-ff dated Approved Design Flow (gpd)
Installer 64,a e.- q-- �U/ /lz� 92Z:4- -+!m
Designer: Ea= � Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �90 N(DC' J° t Ci 1 1 �'I�Z L Nr� h!^g" FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YA'Q
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(( Repair( ) Upgr-a-ddee((tl Abandon( ) an individual sewage disposal system
at'� as described in the application for
Disposal System Construction Permit No. f dated �5— 7 /�
Provided: Construction shall be completed within I ears of the date of this permit. All local condi ' ns must be met.
�-� aS f/
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date %1Board of Health t' V
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