HomeMy WebLinkAboutApp-Permit-Compliance{*�D C —I �O--i 6�0 �l I FEE I1 00
Ab -/ 2, COMMONWEALTH Of MASSAC14USETTS
Board of Health, VTfa 11 rtnl , MA.Tj�� = �
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to ConstructRepairO Upgrade( Abandon( Complete System ElIndividual Components
Location (1
Owner's Nam ( \ CL
Map/Parcel#
Address
Lot#
I•nstaller's Na i c ' �
Telephone#S361_
Designer's Nameerb C� w
Address,, , {� i Q,�,,, SNVi
Addres
Telephone i
Telephone# 53 zka y
Type of Building`Lot Size .5 sq. ft.
Dwelling - No. of Bedrooms Q COQ Garbage grinder( )
Other -Type of Building n / to No. of persons Showers( ), Cafeteria ( )
Other Fixtures ? _
Design Flow (min. required) C6110gpdCalculated design flow �1� Design flow provided — gpd
Plan: Date Number of sheets Revision Date fV G
Title,��J� _
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
r .- \_ ®�\ - - "_ k kt
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrges-to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed -` Date -) -,Cl— a)\(0
Inspections
MA
no
R
NO. (o —106 1 1 � 1. O�ir r /m' ✓ ' E ! 0
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COMMONWEALT14 Of MAS,SACH�, -���3
Board of Health, x+%10,01 rm , MA. , G , f K 16 iy
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ,@<G mplete System �, !
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired( ), Upgraded ( ), Abandoned ( )
by: UG- 1-t-
at
'I
has been instal acc rdance with the grou�isrofis'of 310 CMR 15 00 `(Title 5) ac tea roved design'p`�an as=bY4t plans relating to
application N'6 t ' dated Approved Design Flow . -} (gpd)
Installer
Designer: 'DQ,jN1CAtP
jg2
Inspectoi^ _Date:
The issuance of this permit shall not be construed as a gu tee that the systewill fupction as designed.
No. C—(btv�j A1C C'aN l.�C"tic�1�1 FEE•
COMMONWEALTH Of MASSACHUSETTS -720
Board of Health, (Jj* , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construe Repair( ) Upgrade{ ) Abandon( ) an individual sewage disposal system
at (� �)T" Ly r-�: i _IPJ e as described in the application for
Disposal System Construction Permit No. % dated rX
Provided: Construction shall be'completed within hr�vof the date of this permit. All local conditions must be met.
f�IG�1J ,--'7
Form 1255 Rev. 5/96 A.M. Sulkin Co. CWeslown, MA Date y BoaT'Q O wealth �' f
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