HomeMy WebLinkAboutApp-Permit-ComplianceNo. 8014 DC- -7 317(0 /, FEE 4 W i-00
COMMONWEALTH Of MASSAC14USETTS Ck-*V730qi
Board of Health, VWtM , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERM, IT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location S' l/ s
Owner's Name
Map/Parcel#
Address /S
Jo4 Go
Lot#
Telephone# �
_ d _
Installer's Name �� V lb N
Designer's Name
Address 17 --
Ai 1614�z
Address
Telephone#
Telephone#
Type of Building—ZIla16S e- Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( }
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) gpd Calculated design flow Design flow provided gpd
Plan: Date
Number of sheets
Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
REPAIRS • • • �I '��r,/ 1 t o// L/t l/ Al,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s t to place the system in operation until a Certificate of C 7pm fiance has been issued by the Board of Health.
Signed Date 7
Inspections
No. L Q vii) c - -,31-7(o FEE J T t; 0
C®MMON LTH OF MASSACHUSETTS c". -*( 730 `
Board of Health, N"MOLMA , MA:
CERTIFICATE Of COMPLIANCE
Description of Work; ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), RepairedX, Upgraded ( ), Abandoned ( }
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated 17. Approved Design Flow -----(gpd)
Installer PP-Cjr.'.C;ULUVAN1,
Designer: - Inspector: _ Date:
The issuance of thisipermit shall not be construed as a guarantee that a system will function as designed.
No. i %" � -R c --x\ V I-( k 0 0 eR-- C -'Y -CPPV t FEE 5
5
COMMONNVEALT14®F MASSAC14USETTS C k *I 7-30Qf
Board of Health,Nwi - , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(�� Upgrade( ) Abandon( ) an individual sewage disposal system
at IF -5J lr �`i,-oons) A1%l JJ as described in the application for
Disposal System Construction Permit No.1-, t dated I
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date rR, Board of Health
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