HomeMy WebLinkAboutApp-Permit-ComplianceNo., C�Oi�DC-ii 2.7�� /,Ixl EE 4
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y.1'�� MI -A , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERM, IT
Application fora Permit to Construct( e air Upgrade( ) Abandon( ). - ❑ Complete System ❑ Individual Components
Location
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Owners Name CCS �e `V_A-J.
Map/Parcel#
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Address 3 CO % !
Lot#
Telephone#
Installer's Name
S .,,�
Designer's Name -1V1V O�
Address O
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Address
Telephone# 1,5b- £i lloe
iaW T3
Telephone#
ca tt-
c /t
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) gpd Calculated design flow
Plait: Date Number of sheets
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow provided gpd
Revision Date
Date of Evaluation
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The
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The undersigned agree o inst above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton plat a syste operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 2
Inspections
No. HUSI�S&r ��114E;e(-
Board of Health, O j jam} MA.
CERTIFICATE Of COMPLIANCE l� � f� T���
Description of Work; ®"Individual Component(s) ❑ Complete System h
The undersi ned hereby certify that the Sewage Disposal System; Constructed (if Repaired ( ), Upgraded ( ), Abandoned ( )
by: e
at
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 Approved Design Flow (gpd)
Installer r�- . (1 -
Designer:
._
Designer: r Inspector: 1 Date:
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
No., A)( N P Zi Vele- FEE D.
COMMONNVEALT14 Of MASSACHUSETTS
Board of Health, NA!1l - MA.
DISPOSAL SYSTEM STEM CONSTRUCTIO PERMIT
Permission is hereby granted to; Construct( ) Repair)) Upgrade( ) Abandon( ) an indi-ddual sewage disposal system
at % 3. V Rol-,,rr 2 as described in the application for
Disposal System Construction Permit No. = , 'dated "— 7,,
Provided: Construction shall be completed within three years of the date of this permit All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadestown, MA Date �'� c� /Board of Health �,,7