HomeMy WebLinkAboutApp-Permit-ComplainceNo. O�C�b?� / G�,FEE��
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
APPLICATION FOR DISPOSAL SYSTEMCONSIRtCTION PERM, IT
Application for a PZ�=cA Rep rO UpgradeO Abandon ) -1
O Individual Components
Location ql-)011me-il Rd✓ "' 1 e IAuu
( wn r Na -6401 N Or- 444 O
Map/Parcel# o (o Ef, 3
A r 'ss
Lot#
Tel h e#
Installer's Name �
c
ign is Name
Address�"�Adilress
Telephone#
Telephone#
Type of Building �P Cr
Dwelling - No. of Bedrooms,
Other - Type of Building
Other Fixtures
Design Flow (mina required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( }
Showers ( ), Cafeteria ( )
gpd Calculated design flow Design flow provided gpd
)jr of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS O LTERATIONS W -n -040-T WT -6 iqP- TaI4 MIA) X -n te- r 'Fee -
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees,Lo not to ce the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �c%% -y 46&kiB'i){ r 2? X16Date $ -9'!�—
Inspections
No. 0 6'0-ZJ3 FEE
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ®Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (V), Upgraded ( ), Abandoned ( )
by: 1�.'6r-r-cut( uL'
at 41 -lo raw lh !N t n S cra l.t3P-Yi
has been installed in acc rdan with the rovisions
of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. f - — ,dated Approved Design Flow (gpd)
l�-tJ
Installer 'Vur_ 49 __ /t L _--_- - C ts"opk"—_oy(Z— -
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
.�-- No.VVoO+t'�C-���0`V67i�3..1.�,,... 1_��..,..---- ��`-�.`�UI�.----- ��___�----- _____�__�__-_-`FEE'7eI'�u'__-
COMMONWEALTH OF MASSACHUSETTS
Board of Health, )/A� UrT-ft , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT �
Permission is herebygranted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
r
0�
at 1 Llo Al I r6 av L. ii FRIA
�-+ as described in the application for
Disposal System Construction Permit No. —,->o, dated A/.
Provided: Construction shall be completed within three years of the date of this permit. All local onditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin co.. Chadeslown, MA DateBoard of Health