HomeMy WebLinkAboutApp-Permit-ComplianceNo. �'r7�7 7 1 / ��Lx/C / G� FEE 5OD►° 1 ��7 X03 t
-lei STT
C®I�[MONWEALT,H OF MASS G IJP S
�7� /® �� Board of Health, MA.
� CATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
A plication for a Permit to Construct( ) Repair( ) Upgrad Abandon( - &'Complete System 0 Individual Components
t r
Location .�/L�� ' �J .
I /lGi�7///� fir L iir.,'
Map/Pa rcel#u ✓' '
Address
m"a",.l,rW,, 21
r%� .. ,•-_ . ,
Telephone#,_
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other --Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided Z `gpd
Plan: Date Number of sheets - _ Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
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 a s to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
-Signed Date
Inspections eA d�L
12
COMMONWFALTH OF MASSACHUSETTS
Board of Health, \J Ag"Mfi'~t"r7
CERTIFIGA E Of COMPLIANCE
Description of Work: 0 Individual Com onent(s) Complete System
P P
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),,Repaired i
by:
at
has been installed in accordance witK tl
application No.� �0 r�% dated
Installer f� /n .°i �, a ad . ��' )Z
Designer: <4A�4-
The issuance of this permit
O
)pCMR 15.00 (Title 5)06nd the approved design plans/as-built plans relating to
Approved Design Flow s�.. jii�"gpd)
that the system will function as designed.
No. 6W, Dc -t, 02-7 Ci-iA ' (- + 6 adv -c' -�iarr FEE 51
�-. 00
COMMONWEALTH OF MASSACHUSETTS '�'* 10316
Board of Health, YMM 03j - , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade.andon( ) an individual sewage disposal system
at c / r/ as described in the application for
Disposal System Construction Permit Nol ,date d
�
Provided: Construction shall be completed within b)��ar�cg lithe date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA -Date r/� Board of Health
l
'> - si ,r /ice In ,,/- f'. , % h_ . - -- '-7 --, .ice z' -'V . - "e ✓� , e ,..L