HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1 �bC'� �� 5b L- IJ� "' ' o0 ze, CL FEE
/ �� , -�lr COMMONWEALTH OF MASSACHUSETTS
Board of Health, �)( j9 M0l)"i j , MA.
PP CATI N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
�A i a on for a P rm t to Const uct Repair( U rade Abandon om Tete System 0 Individual Components
PP () P () Pg � () -� P Y P
Location 1 �- �
Owner's Name Wept AC
Map/Parcel# l
Address ,
U )-k
Lot#
Telephone# V I l -
Installer's Name (. hal aAdeo Lr
Designer's Name. mo rid ff
-1�. 1 V1e
Address 30
Address q4t fowl's.
Telephone# Gob
Telephone# Qj
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow Design flow provided j-77gpd
Number of sheets Revision Date
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr to not toewcm
e in peration until a Certificate of om i ce has been issued by the Board of Health.
Signed Date
- Z /, .
Inspections
No. it _��6-��I.7 ip TS,,JFEE
COMMONWEALT14 OF MASSACHUS TS
/f /
e Board of Health, yA lo. Cil ,MA.
�. 7 ! WA
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by: /I k1 r1 ,t (" Ai? t (
at 1 ' tF1 1A
has been installed in accordance xith the provisionsof 31 CMR 15.00 (Title 5) and the pproved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer ( D ( '"'"�
Designer: r :Gt 6Kr Inspector: . Date:
The issuance of this permit all not be cons1rued as a guarantee that the system will function as designed. -
No. 43 OkA D U(Ca "i set k c—Y--C+fA'7j—r FEE
Board of Health, �I� �� t/ �' , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade,(�) Abandon ( ) an individual sewage disposal system
at �Lff, Lt� All 11 R- C., as described in the application for
Disposal System Construction Permit No/j�, dated/ -)-
Provided: Constructionshallbe completed within t o- Fate of this permi 1 local conditions must be met.
Form 1255Re, 5/96 A.M. Sulkin co. chadeslmm,l DavO— _A?/6 Board of Health
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