HomeMy WebLinkAboutApp-Permit-ComplianceNo. b0*DC4(a-9947 l0 ova��t� FEE VV °�
�®��® ITI®�MASS C MT
Board of Health, AW me d i , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair( Upgrade
�AbandonO - Complete System 0 Individual Components
Location q
,' ioane2d
Owner's Name
JO,
Map/Parcel#
i r
a` zX
Address T 7
07 )L4P) Cb,7 4,0,4
Lot#
Telephone#
Installer's Name Phis .01v�d
QY�
Designer's Name
�t�
p CO ��� ��
Address a3
}fin -
h
�,y►-e Address /2) � LIE -3, & Peh,-)_'S
Telephone#
a
Telephone#
Mcg SfoL/
Type of Building 110
t zer— t/' sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder �v J
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures _
Design Flow (min. required) t7 gpd Calculated design flow :55 1 Design flow provided _ gpd
Plan: Date 3 1 1/,& Number of sheets I Revision Date 3 2- 1 -Y'�
Title
Description of Soil (s) Cee Q2J
Soil Evaluator Form No. Name of Soil Evaluator 4'- l` C`t s Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Sef�f Ii�4Siri�
The undersigned afire to tall the above des 'bed ndividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to top th�sys on until a Certificate of Compliance has been issued by the Board of Health.
Signed ( Date
Inspections
No.1 4"i� "'� FEE G(
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ) �' OTW , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage. Disposal System; Constructed ( ); Repaired ( )> Upgraded ( ), Abandoned ( )
by: t= I I S 0 Cc 0-- S C'en S�
at q2Cc►/ -),-
ti-
has been installedin�racc rdance withy e o 'sions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. �{il dated %6 Approved Design Flow. d) ,1'Pt o /�
Installer r%11 al tivrs Ccns� sf l
Designer: r 1 �7 �L hG r a 1 S Ar0,C .I Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. i� p4 t)C 1(o-�9 0t 1 FEE pJ ,Cil
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, ���1 T7 , IA.
; v DISPOSAL SYSTEM CONSTRUCTION PERMIT
on is hereby granted to; Construct( ) Repair ( ) Upgrade(�Abandon( ) an individual sewage disposal system
%)/1�'?�l�9�et� ,��.✓'� S,°tz`�.I9o�°+�`w� 1 as described in the application for
Disposal System Construction Permit No. �� , dated C
Provided: Construction shall be completed wtthin t�of ghee date of this perTit. All local condytions must be met.
t'/YW "n''
Form 1255 Rev. 5/96 A.M. SWkin Co. Chadeslown, MA Date "1 r Board of Health,._ ' U f