HomeMy WebLinkAboutApp-Permit-ComplianceNo. t+DC- (fo " 2.05 4V LD rg(7'6 O T7 ! 0 FEE ^[ d
COMMONWEALM OF MASSACHUSETTS
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( - ❑ Complete System Individual Components
Location
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Owner's Name —C
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Map/Parcel# QNJ
Address 99 �j ,
Lot#
Telephone# !, q —
Installer's Name PK m
ConMac�r�s �A C_
Designer's Name DD um
Ce, L o11)ee_M
a
Cape,
Address 3 f3-Ia.Kum
12oe� Pd- C denn�S M11Address
q,3Hot;,,) Si-,
° r Hiq wo S
Telephone# m
Telephone# -
(p ? - 4,5
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Type of Building esi ae o-+ o 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 Design flow provided b gpd
Plan: Date 1 %' ) yl�n I t Number of sheets Revision Date
Title J aL� y D nS
Description of Soil (s) a S
Soil Evaluator Form No. r) Name of Soil Evaluator t^ !, rk Date of Evaluation
OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to the s, m Aeration until a Certificate of ompliance has been issued by the Board of Health.
Signed =nDate QWC9.8 i
Inspections
No. �'J6kA'? - (o-07—Oc-5
COMMONWEALTH OF MASSACHUSETTS
FEE t Q
W,
Board of Health, _ y .!'l/l o tm, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: vidual Component(s) ❑ Complete System < C:i�o Z1
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded , Abandoned(
by:
at l C n
has been instar n accordance with the provisions of 31 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. % G _�dated ' -` _ Approved Design Flow gpd)
Installer _ J_T
Designer: �`j r Wn r Inspector: Date: _
The issuance of this permit shall not be cons d as a guarantee that thle system will function as designed.
No.� i � ` 1( �j � { % /► - - - — ----FEE T `
A COMMONWEALTH OF MASSACHUSETTS (6 3 zS
Board of Health, w/ em o avf MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade; Abandon( ) an individual sewage disposal system
at�^ as described in the application for
Disposal System onstruction Permit No % t+ F dated
X
Provided: Construction shall be completed within tt o" t `rhe date of this per it. .local conditions must be met.
Form 1255 Rev; 5/96 A.M. Sulkin Co. Chadeslown, MA Date' T r oard of Health n