HomeMy WebLinkAboutApp-Permit-ComplianceNo.
/6- _53
COMMONWEALTH OF MASSAC11IUSETTS
FEE
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( Repair( Upgrade ZAba.don( ❑Complete System...(J dividual Components
Location -+ &/tf a4A A WaA, Vq JAle d V_rk
Owner's Name 1kt %
Map/Parcel#
Address Lo aoblancL YA-VA&QUIV
Lot#
Telephone#
Installer's Name Nwx avdN_yJw v.
Designer's Name `�r1J 1V �►1C
Address"�9/ m V
Address D &�, 1-1 Z A) ILk
Telephone# 0 �)
Telephone!L,500 21 —'_3U00
Type of Building Lot Size I sq. ft.
Dwelling - No, of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Capteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre s to not to pce the s tem in peration until a Certificate of Compliance has been issued by the Board of Health.
Signed C = Date �_
No.:FEE
COMMONWEALTH OF MASSACHUSETTS 6)� 17,1��el�lep
Board ofHealth, -------- y1mC)imt MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ,,l-I`ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (�, Abandoned O
by: h fAe-d au, A a t ,1::::�
at < .t 12 1
has been installed in accordance with the provisions 6V 310 CMR 15.00 (Title 5) and 64, proved design plans/as-built plans relating to
application No. - �'' d/ated. 2 7 T// . Approved Design Flow (gpd)
Installer f,i /7 f A�1 / /�/l dam_ __ _ -r-
Designer:e1=�4 / Inspector: '! F Date:
T
The issuance of this permit shall no a construed as a guar thaft the system will function as designed.
No. —f —�FEE l x CC, /V
_
Board of Health Vi4A��Q MA.
DISP05,M,,.. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Constriiet( ) Repair( ) Upgrade Bandon( ) an individual sewage disposal system ".
at ^ t ', r a i, �� ��t in �,_ as described in the application for
.
Disposal Systeun,Construction Permit No. JA dated�-
Pro
vided � C dAst G on shall be e�pm-pleted withinxh ���f�at� f this pe i All local colic itions must be me!,C
3 Date.:: oard of Health
Tvmm 125 RJev 5`�J6 A M.1Sin
�ulrRCo ChadestdNny; MA
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