HomeMy WebLinkAboutApp-Permit-ComplianceNo. fd �b-133 6LD 1 l f 1 1_ V o Z O S FEE 0()
COMMONWEALTH Of M ASSACITUSETTS
Board of Health, Ag , MA. Cl � /y s
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APPLICATION FOR DISPOSAL SYSTEM C®NSTRUCTIO=Components
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Application for a Permit to Construct( ) Repair( ) Upgrad ( Abandon - Ll Complete System
Location
Owner's Name73
Map/Parcel# �1
Address to ncocO e.6 Cc.r rn
Lot#
Telephone# _ - qa
Installer's Name LobezidV
Designer's Name
Address/4LaczL
Address 2�SV 0-nN1�y
Telephone# 50L_
Telephone# -z
Type of Building
Dwelling - No. of
Other - Type of Building
Other Fixtures
Design Flow (min. •egnu. d) Cl gpd Calculated design flow
Plan: Date t! I Number of sheets C__12__
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
_Pl
DESCRIPTION OF REPAIRS OR ALTERATIONS
No. of persons
sq. ft.
Garbage grinder( )
Showers (, ), Cafeteria( )
-- Design flow provided
Revision Date
Date of Evaluation
gpd
The undersi ees to install the above de 'bed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further s to OMP -Place th em in pe tion until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 10 12L21 Ik:,
Inspections
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No. & U H D c'1(6- l 3.3 3, FEE 455-00
COMMONWEALTH OF MASSACHUSETTS 1b �4q, �Z -48
48 C?
Board of Health, �A�2.1VI Qt1T�f , MA. `1
CERTIFICATE Of COMPLIANCE
Description of Work:Individual Component(s) ❑ Complete System
The undersigned her certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedAbandoned ( )
by. _ . „ f.
at n r im
9
has been installed in accordance withAd the provisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicati�No. dateApproved Design Flow (gpd)
Installer k, 0 QeY-I \J Z7 ddL-°
Designer: ,� d ' Inspector:MW_ADater /� ~^ 4
The,.issuance of this permit shall not be construed as a guar tee that the system will function as designed.
FEE � X00
COMMONWEALTH EALTH ®F MASSACHUSETTS A -,o gro3�
Board of Health, �/�6-(L/ti'10l)- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(
at
Upgrade Abandon ( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. /t2 _� <54-", datedI�/T-1. b.
Provided: Construction shall be completed within tiv=4 �o"f��,��Adate of this permit All local conditions must be met.
//'' 1
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 'A Board of Health 54