HomeMy WebLinkAboutApp-Permit-ComplianceNo. 20ODC^ l 6 " 62-01 L 0_111 - l-1 J 000 le -3 FEE �� QCOMMONWEALTH OF MASSACHUSETTS cD
-714
Board of Health, , MA.
PLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
plianon or a Permit to Construct( ) Repair( ) Upgra AbandonO - ❑ Complete Systeme-6 Individual Components
1
tion 4 (A ¢ r- d
Owner'sName/Parcel#
Address
q' L
r
Telephone# St); .3.
0 9 -ller's
Name
Designer's Name tef- Enq ne-F—rp r-)
Address�M
P
Address c�63 5
i-ke 6 DeYA6
Telephone#�✓�
Telephone.# 4106
Type of Building j ryd alLot Size �® � sq. ft.
Dwelling - No. of Bedrooms V Garbage grinder( )
Other -Type of Building No. of persons Showers ( ); Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
gpd Calculated design flow
Number of sheets
Design flow provided
Revision Date
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
gpd
Thede ;i d agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre s o not to ge the s tem in operation until a Certificate ofd mpli �e has been issued by the Board of Health.
Signed Date/
Inspections1V j°�.,i 1 «i ��V�
f
No. G� SJ� {p 1 I°K[t �i f E. 5,5,& Y
C®MMONWEALT14 OF MASSACHUSETTS
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Board of Health, YA- M O t ice-
CERTIFICATE Of COMPLIANCE `, . toi�ttso
Description of Work:vdual Component(s) ❑ Complete System'
The undersigned hereby c�er ' atthe Sewage Disposal System; Constructed ( ),Repaired( ), Upgraded_�J,' bandoned ( )
by. i') i ? 1 1
"c
at 1 f T. r' Y t? F
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ,dated! "' a?=Approved Design F1ovV3 4Zf (gpd) f
Installer l iZ Cl 4 �, rC VtLII d C. iwOG./ "`.' u°t d l Y
Desgner:,���� �.+Di ^ �� l,� r r r?�� �>t'Inspector:/k` Date:
The issuance of this permit shall not be construe as a guar tee that the system will function as designed.
No. _ � r` .i T � �O '"Le Z � � � � � . 4 f � %� 1 FEE 5 00
COMMONWFALTH OF MASSACHUSETTS
Board of Health, Y MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby ntedto; C struct( ) Repair.( ) Upgrade�Abandon( ) an individual sewage disposal system
at
. rear c o e � as described in the application for
/
Disposal System Construction Permit No. dated
�
liKl1.
Provided: Construction shall be completed within >;lF�ars of the date -of this permit. All local conditions must be met.
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Form 122555 Rev, 5196 A./Mf. Sulkin C/o. Chadeslftown, MA/ Date Board'of Health ,' _ A �✓
5:S '��1 �� !H 414•f .i'J :-V�.; ✓4.. � F'"/ `c���� f •,YN/:>�.-