HomeMy WebLinkAboutApp-Permit-Compliancekmel —00 14
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No. 9QoC�1
FEE
COMMONWEALTH OF MASSACHUSETTS
USETTS
Board of Health, MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(; Upgrade( ) Abandon( ) - 9(complete System ❑ Individual Components
Locationp? 1, W,;')!4/2A ,
Owner's Name 6'13Aen6i"
Ma /Parcel#
p $
Address Cyd �G
Lot#
Telephone#
Installer's Name I .fir w1 o
Designer's Name T •
Address t�^^ r
Address
Telephone#
t Telephone# • ��
Type of Building Lot Size /U, "V sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow((m�� in. required) a gpd Calculated design flow Design flow provided 336 gpd
Plan: Date'4Fe.h, ii 2o0) Number of sheets Revision Date
Title I
Descril
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned a to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of to pl a the system in operation until a Certificate of Cqtnpli ce has been issued by the Board of Health.
Signed Date �� ��
Inspections
�� V
COMMONWEALT14 Of MASSACHUSETTS 4L 1-7
Board of Health, (L(1774, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) & Complete System
a
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, Upgraded ( ), Abandoned ( )
at a.,�: I �t.zw-f� Ir;c i'a {}fufll
has been in talled in`ccordance with the provisionsof 310 CMR 15.00 (Title 5) and the aproved design plans/as-built plans relating to
application No t dated ice, % % . Approved Design Flow` °fa (gpd) �o
incrallpri"�:r ! 9. "? rs v-, K r: :1 ti_t..e__. 1 P�;•;uri tsP.tc 'i l ,{Ji1 Fi.I°. /.r .Z'1�. �tC'_ 'ti'(�
Designer: ; „7. %< _> t, o s. nec., : r l;t. Inspector: 1440-
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No e" a!«.. �. d e. v: t, i s FEE `,� �' C,)
ice^ ac�? �;� ���- ..-� ! " f 7 �' 4.t
COMMONWEALTH OF MASSACHUSETTS
Board (?f Health, Y#.�i111)%>t'f , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(' Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. 1 ',I r� dated
Provided: Construction shall be completed within thr ) Vo the date of this permit. All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chalestown, MA Date '-i /;9oard of Health`T �> rr�0 �% A` $