HomeMy WebLinkAboutApp-Permit-Compliance« No.,'66WIDC--(6iI3>8 /W ;r/,50Z T4,141 <— �ee FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (-.44pgrade ( ) Abandon( ) - ❑ Complete System ndividual Components
Location
Owner's Named
- v�
Map/Parcel#
Address L�
Lot#
Telephone# 4 _-30
Q � C�
Installer's Name r
Designer's Name.
Address ��. �� o
Address
Telephone# ��"p �- p' C"
Telephone#
Type of Building�Lot Size sq. ft.
Dwelling - No. of Bedrooms 7) Garbage grinder( }
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) . gpd Calculated design flow Design flow provided. na ;-D gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS CAAM NA4 r ,=
Jr
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 place the syste operation until a Certificate of Com liance has been issued by the Board of Health.
Date /
Signed `� J
W
No. FEE
Board of Health, ��"}�, MA, d
CERTIFICATE Of COMPLIANCE NC !' e
Description of Work; l�lndividual Component(s) C3 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired V, Upgraded O, Abandoned ( )
at 2:3YC
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. dated Approved Design Flow;(gpd)
Installer \-G �a. l �r .. rcrn_, t -'r" t xc' m t c J d .
Designer: Inspector: Z�`�k-IA lv - %. Date: 1W %�
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.&%A : %A C c —113.8 ( K.. o rJ i-a-�L— FEE
Board of Health, YARM 0l E M- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) R,eplair(v)°1**�Upgrade ( ) Abandon( } an individual sewage disposal system
at �` N�� �� �,���`✓ as described in the application for
Disposal System Construction Permit No. dated L�/Y
Provided: Construction shall be completed withii f tFie date of this per it. All local con itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date le) f pard of Health ;
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