HomeMy WebLinkAboutApp-Permit-Compliance}' O{�C—ib— � I �7 p �rj � FE" E
a /0 C®MMONWU LTII Of MASSACHUSETTS
Board of Health, YA �hqoTi4
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construe Repair( ) Upgrade( ) Abandon( ) ---d Complete System ❑ Individual Components
Location 6a
Owner's Name
Map/Parcel#
Address 63 jj ✓��
ej
Lot# 99
Telephone# y'p -1
060 3
Installer's Name l
Designer's Name
Address ^�Address
;L(�2
Telephone# 5o5k 3qQ 49 q aTelephone#
C509 3
$ da
Type of Building —
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size � d sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria (
Other Fixtures /� /
Design Flow (min. required) �U gpd Calculated design flow Design flow provided 4 pd
01
Plait: Date Number of sheets Revision Date
Title ago,
"-
Description of Soil (s) j4Q.Q/►ti
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS .._ Uz AQX.AM-
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to lace the system in operation until a Certificate of Co pRance has been issued by the Board of Health.
Signed Date
t Inspections
C®MMONVEALTI-I OF MASSACHUSETTS
Board of Health, MAM O ynt MA.
CERTIFICATE Of COMPLIANCE
•
FEE �1110.
ck tl��.(. 00
�j
Description of Work: ❑ Individual Component(s) omplete System
The undersigned hereby cer qy that the Sewage Disposal System; Constructed (/Repaired ( ); Upgraded ( ), Abandoned ( )
by: A ' -
at
has been installed in accordance with the rovisions ofPO 0 CMR 15.00 (Title 5) and the/ r ved design plans/as-built plans relating to
application No. dated Approved Design Flow me .
Installers �'-)r� ,P'a oA,,. /' 14 ton A
Designer: ")61Lea I reran Inspector:` 4 ( ' LC-' 'W� Date: 7 :.e-7 "-7' leo'
The issuance of this permit shall not be construed as a gual /tee rat the system will function as designed.
No.
r 6 /97
0°Lc)oG �
COMMONWEALTH Of MASSACHUSETTS
Board of Health,V A �"I i j"Rlt MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE $110, ,' ' . i {�
965
Permission is hereby granted to; Construct(/) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at / as described in the application for
Disposal System Construction Permit No. Ito ' , dated' _P'i
Provided: Construction shall be completed within tj�1f the date of this permi . All local condi' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date Board of Health