HomeMy WebLinkAboutApp-Permit-ComplianceNo. o4 (6 6(lo2- �f� _r ✓ C)FEE
t�3 C®MN][®N I.TIT ®r NIASSACIIUS11-TTC &4;4218
Board of Health, '1 0 , MA.
APPLICATION FOP, DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
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Application for a Permit to Construct( ) Repair(L4pgrade( ) Abandon - El Complete System glf;ndividual Components
Location
Owner's Name
Map/Parcel#Ai,>abe)
Address
Lot# AlTelephone#
Installer's Name
Designer's Name' G4d Ila
Address /
J �
Address Z�� d�`%IIfFUV
Telephone#
Telephone# % J' (jG�
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)TPi gpd Calculated design flow
Plan: Date 7 / 9- l!4 Number of sheets
Title
Description ofSoil(s) _
Soil Evaluator Form No.
of Soil Evaluator
Design flow provided gPd
Revision Date
of Evaluation /,- 7,.?" A�
DESC:RTPTTON OF REPAIRS OR ALTERATIONS // %/I eXY / _ -��l
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to notrt_o/p'ace a cyst m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 2'
+ Inspections ��f�. �� �/1-r/'��;. �Z'��..(r.6�! Q
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C®MM[®NI.TII Of MASSACHUSETTS ow�lt(, rj?#(o�8
Board of Health,�� t.� 1 IT 0",
CERTIFICATE OF COMPLIANCE
Description of Work: Wfudividual Component(s)
The undersigned hereby certify th tithe Sewage Dis
by:
at
❑ Complete System
/gja1 System; Co structed ( ), Repaired ( ), Upgradedandoned ( )
has been installedin a �r nce with the pvis. ns of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No dated . Approved Design Flow12i�� / (gpd)
Installer A4, kea , Raf-?tJJJj
Designer: /C ,rte C>vt �� Gs!� r> [ Inspector: Date:
The issuance of this permit shall not be construed as a tee that the system will function as designed.
7,
No. '3EtCC.-{ - 01(o�. FEE
t'� o
COMMONWEALTH OF MASSACHUSETTS ck4 G 2-18
Board of Health,Y "d mlo / i' , MA.
DISPOSAL SYSTEM'CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrad&, Abandon( ) an individual sewage disposal system
at 5 LJas described in the application for
Disposal System Construction Permit No. �'% dated 1� e -//6..
r5
Provided: Construction shall be completed within-grfer-of the date of this permit. All local cot f iti s must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date___ Board of Health