HomeMy WebLinkAboutApp-Permit-ComplianceNo. 13o1+ (072_J-( FEE v00
'&Yi_ftSSAC11USETTS 44[/6,34
Comm N WV�E.
H 6
Board of Health, � J MA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) RepairwUpgrade( ) Abandon( - �Complete System ❑ Individual Components
Location e L
Owner's Name �� v
Map/Parcel#
Address /,2
111e%RC'
Lot#
Telephone# 6 P?
Installer's Name �Vrlo
Designer's Name.
G
Address y�.1� S�Aj
Address 93 g Qin
!ik
Telephone#y - 917 7, 2 Cr
Telephone# 5'UW , 3
Type of Building Lot Size /01 !?05 sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min, required)
Plait: Date
Title t + 44
Description
Soil Evaluator Form No.
330
gpd
Calculated design flow
hP�Ts
Design flow provided 3- gpd
Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees tojbistalflp above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place t system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �i2_�_ Date
Inspections
No. (c ap "C — 1 COMMONWEALTH OF MASSACHUSETTSFEE < Q!_
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) L: Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired,(JI Upgraded ( ), Abandoned ( )
at F, y , ,.Zoo,,1,r G�.
has been installed in accordance with the provisions o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application Nogt
s3 "" j•r dateLdt�(.� F �� Approved Design Flow (gpd)
Installer &t" u; r; ! . l ° E', STr �.tr� " 1 _ e0Ar--G ' f LOTM
Designer: 4
Inspector:
Date:
The issuance of this permit shall not be construed as a guar ` tee that the system will function as designed.
No..cl 130 a2. ,OTn FEE 00
/I _ 0— COMMONWEALTH OF MASSACHUSETTS USETTS ° 1 X36
Board of Health, �J�U MA. _.._
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
at
RepairxfUpgrade( ) Abandon(
d4 r an ai..►"t-A i e� r-,--
k"'
6 Disposal System Construction Permit No/ , dated
an individual. sewage disposal system
1
_'as de-sC'ribed in the application for
Provided: Construction shall be completed within thrac yt r_s of the date of this permit. All local conditions must be met.
/
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ,/,s�` Board of H tf
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