HomeMy WebLinkAboutApp-Permit-Compliance{ No.fV�— 1 bite- � FEE ��� .
�®��[� �1CTII ��' �A CC��IT'UC�TTC X30�7
Board of Health, � � , MA.
APPLICATION FOP ISI POSAL SYSTEM CONSTRUCTION P RMI IT
Application for Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location
Owner's Name (H -ell
Map/Parcel# (43 t
Address
Lot#
Telephone#
Installer's Name Cao Co t� v
�G Ij)p Designer's Naive
Address �� `j K (,
�I / Address
Telephone#.Yo$ qyo ?,50c)
Telephone#
Type of Building IN -r— _l 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 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 ' TERATIONS ,e & dX CqN a�
vc r (Iii PT d Arofff
11211 0
The undersi es to' tall the abov i ividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr o t the syste radon until a Certificate of Comlihas been issued by the Board of Health.
Signed Date '✓� _(%_(TIF
Inspections
No. CJ oAAVC -7--:';, 719 FEE
C®MMONWEAILTII OF MASSACHUSETTS A -,;V7 ~7
Board of Health, Aa.( C)t , MA.
CERTIFICATE Of COMPLIANCE
Description of Work:Individual Component(s) ❑ Complete System
The undersigned hereby certig'y that the Sewage Disposal Systerr4; Constructed ( ), Repaired/,Upgraded( ), Abandoned ( )
by: i Ca (oc)l
at
I
has been installed in accordance with the 0 3provision: 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. L, dated�Apprvved Design Flow�(gpd)
__. t t <
Installer V, x, -
Designer: Inspector:
The issuance of this permit shall not be construed as a guara
Date:
that the system will function as designed.
COMMONWEALTII OF MASS C USETTS
Board of Health,11M 11 MA.
DISPOSAL SYSTEM ONSTRUCTION PERMIT
FEE "
�0-77
Permission is hereby granted to; Conssttru t( ) Repair ) Upgrade ( ) Abandon ( } an individual sewage disposal system
at S3�`�`f) vagi K as described in the application for
Disposal System Construction Permit No.dated
Provided: Construction shall be completed within tleeay rs oft e date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date -J�L/_/ Board of Health '� }
f