HomeMy WebLinkAboutApp-Permit-ComplianceNo. Bo AW -17-3 I 2-0 /l �s 7 FEE
174'- 5 COMMONWEALTH Of MASSACHUSETTS cOr� Q3o �
Board of Health, _ ,
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System Individual Components
Location
a r, � F AVE
Owner's Name 04A?,C Q �
Map/Parcel#
�j(�j �'f
Address -430 V��ak.t S -c T�m r aqAot MA
Lot#
Telephone#
Installer's Name C�p�C�ltC E 17 5
Designer's Name A
Address `
C�, -S� i4
Address
Telephone#-
C f 2_ 8 g
Telephone#
Type of Building C�=s� iCij L- Lot Size sq. fr.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plait: Date
Title
gpd Calculated design flow
Number of sheets
Design flow provided
Revision Date
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
gpd
DESCRIPTION OF REPAIRS ORALTERATIONS ':rio5 14L4, t4 -to AoD R-i45oP ,
Z16,95i1E-L i<ac "X1x 5 FP -0•c -t 6C- ? i TA %::. `tV D -
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date '(O ' a C) L%
Inspections
.. ,\ )c-47---5 12-
_. COMMONWEALTH ®F MASSACS
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poi
Board of Health, A -M Q 1r%$ , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Components) ❑Complete System moi' -`/V
The undersigned hereby ccrrtlif-y that the Sewage Disposal System; Constructed ( ), Repaired X, Upgraded ( ), Abandoned ( )
at �� Fre)--,?" A
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved
application No. dated -4 / 7 . Approved Design Flow (gpd)
Installer 0�Are�AJChe
Designer: Inspector: ,�
The issuance of this permit shall not be construed as a guarana th
plans/as-buili'plans relating to
Z$?W -472--
Date: 7 -4 � :: a/
Cthe system will function as designed.
No.� u '17 L Lo (24- e: -W 1'DE FEE 5�7 . OU
/ 7 �' _ COMMONWEALTH LTH Of MASSACHUSETTS c�e�Q3 o t
Board of Health, _)W.MQ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair(K) Upgrade( ) Abandon( ) an individual sewage disposal system
at oda Ff o6r A VLA' as described in the application for
Disposal System Construction Permit No. 7 dated 4(- 7
Provided: Construction shall be completed within "{s;14he$ate of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, SMA Date `� / oard of Health�