HomeMy WebLinkAboutApp-Permit-Compliance• No. � � 7.- � G��� %��u/--G�is�Y� �TS�� FEE ��2�%�
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Board of Health, yffj4D 0n4 4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a,Permit to Construct ORe air [YePgrade Abandon 0 Complete System -Ekldividual Components
Location
Owner's Name
'
Map/Parcel# 41/ ®�
L _ . 0�c
Address Z2 -4,2-
Lot#
Telephone#
Installer's Name 2/�J1911, V
Designer's Name
Address
Address
Telephone# —All.— Z
Telephone#
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.
DESCRIPTIONO REPAIRS
'7O' 1 /a
Lot Size sq. ft.
Garbage grinder { )
No. of persons Showers ( ), Cafeteria
gpd Calculated design flow Design flow provided gpd
Number'of'sheets Revision Date
Name of Soil Evaluator
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 agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
v
Inspections
No. ( ✓ ' % 7 FEE
/T <
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
CERTIFICATE OF COMPLIANCE
.5.
Description of Work:. Q<dividual Component(s), ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( graded ( ), Aband e O C
by: - Z _>
at
has been installed in accordance with the provisions of
application No.. / , d ted -ZIQ ` l
Installer�'r�°C
Designer: Inspector:
The issuance of this permit shall not be construed as a guarai
) CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
Approved Design Flow ---"* (gpd)
(.t� AZA111 Date:
---e)
>e that the system will function as designed.
FEE
COMMONWEALT14 OF MASSACHUSETTS
S
Board of Health, YA/<'.J1 6 U]%H , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair �''U�pgrade ( ) Abandon( ) an individual sewage disposal system
at IFO & Azo �/`S;, as described in. the application for
Disposal System Construction Permit No. dated 129
Provided: Construction shall be completed within three years of the date of this perin a 1y ill local condi ' s must be met.
Form 1255 Rev. 5/96A.M. Sulkin Co. Chadeslown, MA Date �G)' �l Board of Health �f