HomeMy WebLinkAboutApp-Permit-ComplianceNo. 50t4 FEE16 Ck* c
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, _MA.
V�'yld�l�H ,
X�PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
plication for Permit to Construct( ) Repair( ) Upgrade Abandon( ) Complete System ❑ Individual Components
Location d _ CQ)
Map/Parcel#
i
Owner's Namej
Address as fl
Lot# da
Telephone# . _ o)30- o
Installer's Narner.
Designer's NameOr 104 SSC. �e
qs--Zo a ` S
Address/4
Address cI n
Telephone# spg_ % -_ 3
Telephone# sv8. X39
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min.
Plan: Date Q
Title _�,?�_,
uired) oR a-0 gpd Calculated design flow
Number of sheets _-
Description of Soil (sl i
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
of Soil Evaluator
Lot Size sq. ft.
Garbage grinder( }
No. of persons Showers ( ), Cafeteria ( )
Design flow provided ;533 gpd
Revision Date
Date of Evaluation
The undersigned agrees to ' the ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to cethe-s tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �~ Date fad ��!V
Inspections
No. "1 f)b 1 (a ( FEE
COMMONWEALTH OF MASSAC-BUSETTSel
Board of Health, M0(M* MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System y
The undersigned here b certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned (
by: )4-)r jam" � C ` t ,err—� f+ c!
at. f7f i 14 i1 r i, 5�' C4
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 0� h Approved Design Flow (gpd)
Installer i ° x � i_ G r 1` _ (� ri at i-! nx-i ne s n
Designer: 3" ¢ re �r,c. ; j2t,�-Cc FSP. +; , " Inspector: 2,42r''' ` F., Date: 7 r°
The issuance of this permit shall not beconstrued as a guae6 tee that the system will function as designed.
No. 11�n1AV,)C— �� �(^t�(1 ('�jl.i� FEE It
COMMONWEALTH OF MASSACHUSETTS Ck-�- t 2A 3
Board of Health,YM0� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (J< Upgrade( ) Abandon( ) an individual sewage disposal system
at i ! �r- z e r x.,' , r'i�s '- r'-' .7 n, �l as described in the application for
Disposal System Construction Permit No, dated '`-
Provided: Construction shall be completed withiniliraa-44ars of tie date of this permit. All local co tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date L. -t oard of Health
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