HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSACHUSETTS
Board of health,YYMYyLOW-14 , MA.
FEE
APPLICATION FOR ISIS ®SAS. SYSTEM CONSTRUCTION APER IT
Application for a Permit to Construct( ) Repair( UpgradeO Abandon( - ❑ Complete System ❑ Individual Components
Location U(" r ('�
Owner's Name e (%e
Map/Parcel# 13/,/
Address
Lot# 101
Telephone#
Installer's Name CaPP O 5effl
(,,'C: "jZo- 5W-eC(1Z4j
Designer's Name.
Address _/J` ,
G(t jJT, 1 07
Address
Telephone# 5()S J Z 506
Y - g2 -Z2 g
Telephone#
Type of Building
t
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min, required)
Plait: Date
Title
Lot Size
No. of persons
sq. ft.
Garbage grinder( }
Showers( ), Cafeteria ( )
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTIONF REPAIRS OR ALTERATIONS -e ILR�� �cJ �Q (� cd
c rn 1 r tj
(7tC�FC • (0Cd +d
The undersigned agrees to install the abovl described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ` i Date
Inspections
No. f.
COMMONWEALTH O 1-y ASSAC1t1t SETTS e ,A ,ry V>• FEE
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andofHealtlt,,, " AL4.
ERTIrICATE Of COMPLIANCE QdCGf
Description of Work:ndividual ` onent(s) ❑Complete System...
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The undersigned hereby certify that the Sewage Disposal System; Construc �d ( ), Repaired ( Upgraded ( ), Abandoned ( }
by., �. ,i^, (C ( �Git P (c CC�� ^?�l?i.'?
at ~C
has been installed in accof dance with the provisions of 31=0' CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicatpoYr No. 1' l dated "a — I t/^ I (.- Approved Design Flow - / (gpd)
Ixistller ��'C�%t (; ;G(_l} lC* F (nod C'/' -
f
Designer;., Inspector: rr`] �l""'"i ° Ilate: !S
j The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. � i FEE _ 5y
COMMONWEALTH OF MASSACHUSETTS
Board of Health,y (;Zk4C)l
DISPOSAL S YSTEM � NSTRUCTION PERMIT R(y rG
Permission is hereby granted to; Construct( ) Repair( Upgrade ( )...Abandon( ) an individual sewage disposal Or
m
1
at ly 3 y�`^ t`� �''V as described in the application for.
{ C
Disposal System Construction Permit No. % dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulki6Co. Chadeslown, MA Date ? l �� l � Board of Health f