HomeMy WebLinkAboutApp-Permit-ComplianceNo. k/V�[ CSI ��i'v"� FEE
30 r
C®MMONW LTH OF MASSACHUSETTS
g Board of Health, V ivlaOT%a MA.
; f SPP I ON ® ➢� ��®� �. �'ST'lI CONSTRUCTION PERM
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A 1 radon for a Permit to Construct( Repair( Upgrade(✓fAbandonO 'Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
Address C
Lot#
Telephone#
Installer's NameyCl, —'
Designer's Name 4
Address `
Address (� `<r 4 � � M
Telephone#
Telephone# -7.2 f _.
Type of Building �,c®� , Lot Size sq. ft.
Dwelling- No. of Bedrooms _ Garbage grinder ( )
Other Type of Building No. of persons Showers( ), Cafeteria ( )
C�
Other Fixtures J 7' J
--
Design Flow (mina required) Z�:D (D gpd Calculated design flow Design flow provided- gpd
Plan: Date �J I S I C 'i Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Z . V . (mer r,v�, Date of Evaluation n J
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system ' eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
r Inspections
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C,VLI-, "�,- ��-
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WT�COMMONWFAL114 OF KOSA T.
Board of Health, )Lpt9i1ho1yn+ , MA. D. 6L
CERTIFICATE Of COMPLIANCE l
Description of Work: ❑ Individual Component(s) %a"Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
at
has been installed 'nracc ,�a#with theprovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / / dated .Approved Design 1714�6f d)
Installer jU v
Designer: k�l..ts P S. c.t� Inspector: _3'ti Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as, designed.
- No. ovr DC -1 I -Q2-09 -09 RE %\D-1 U i C FEE
COMMONWEALTH Of MASSACHUSETTS ck-+ 30b3
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(_) Repair( ) Upgrade K�' Abandon ( ) an individual sewage disposal system
at T X k13
Disposal System Construction Permit No
—f 4� dated.
as described in the application for
Provided: Construction shall be completed within three years of the date of thi )errpit. All local ditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown,MA Dated+ / ! Board of Health 'f