HomeMy WebLinkAboutApp-Permit-ComplianceNo. 164DO -f -740GO
FEE � � 5-5100
COMMONWEALTH OF MASSAC114USETTS
Board of Health, 7 �}` -j MA. awl 11�F�l
Lu
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Ap lication for a Permit to Construct( ) Repair�/Upgrade( ) Abandon( - ❑ Complete Systemndividual Components
location � Q Ave- Owner's Name m e ,�;7cse -e
(ri If ap/Parcel# /�l >1117,o, h fl
Type of Building e i Lot Size sq. ft.
Dwelling No. of Bedrooms Garbage grinder ( )
Other - Type of Building No, ofersons Showers
p O,Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
OF REPAIRS OR A'LTEF#PONS 1(1 4- 4 (I 1e w n d ff � V k -e
t
The undersi e*totall the above scrib nclividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr sthe system," don until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 5'-3-17
Inspections
No._�hfl�C t i ti�
17 COMMONWEALT14 OF MASSACHUSETTS FEE 'SK 00
Board of Health, y n t - , MA.
�, CERTIFICATE Of COMPLIANCE �f
Description of Work:Inchvidual Compdiient(s) ❑ Complete System
The undersigned hereby certify tha t
by. Ghe Sewage Disposal System; Constru ted ( ), Repaired �pgraded ( ), Abandoned ( )
r' j
at Villl V�
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.`77 �,9 dated proved Design Flow Z2�7) (gpd)
Installer
Designer: Inspector: -4 ? -f :7
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �nl4A)C-1-7-q0(00 Cop SSC 1tvSP FEE �. 0co
COMMONWEALTH OF MASSACHUSETTS CA* 313 �
Board of Health, VWAX0Ql l , MA.
DISPOSAL SYSTEM[ CNSTRUCTION PERMIT
Permission is her�byXb-�
gnted to; Construct( ) Repair( Upgrade( ) Abandon( } an individual sewage disposal system
at ,�00 , / i%� as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed withittiGof date of this per 't All local con 'tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Challeslown, MA Date Board of Health
Address
Lot#
Telephone#
Installer's Name
lr
(nDesigner's Name
Address _
t 0
Address
Telephone#b-M
7-7
Telephone#
Type of Building e i Lot Size sq. ft.
Dwelling No. of Bedrooms Garbage grinder ( )
Other - Type of Building No, ofersons Showers
p O,Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
OF REPAIRS OR A'LTEF#PONS 1(1 4- 4 (I 1e w n d ff � V k -e
t
The undersi e*totall the above scrib nclividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr sthe system," don until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 5'-3-17
Inspections
No._�hfl�C t i ti�
17 COMMONWEALT14 OF MASSACHUSETTS FEE 'SK 00
Board of Health, y n t - , MA.
�, CERTIFICATE Of COMPLIANCE �f
Description of Work:Inchvidual Compdiient(s) ❑ Complete System
The undersigned hereby certify tha t
by. Ghe Sewage Disposal System; Constru ted ( ), Repaired �pgraded ( ), Abandoned ( )
r' j
at Villl V�
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.`77 �,9 dated proved Design Flow Z2�7) (gpd)
Installer
Designer: Inspector: -4 ? -f :7
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �nl4A)C-1-7-q0(00 Cop SSC 1tvSP FEE �. 0co
COMMONWEALTH OF MASSACHUSETTS CA* 313 �
Board of Health, VWAX0Ql l , MA.
DISPOSAL SYSTEM[ CNSTRUCTION PERMIT
Permission is her�byXb-�
gnted to; Construct( ) Repair( Upgrade( ) Abandon( } an individual sewage disposal system
at ,�00 , / i%� as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed withittiGof date of this per 't All local con 'tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Challeslown, MA Date Board of Health