HomeMy WebLinkAboutApp-Permit-Compliancea No. r,0Aj �Y l.L C� �FEE 5- 0O
r� r COMMONWEALTH Of MASSACHUSETTS 008(0R q
LU
Board of Health, V,
49JI400T34 MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Apj lication fora Permit to Construct( ) RepairV Upgrade( ) Abandon( -
❑ Complete System ❑ Individual Components
cation 9
Owner's Name PewL Pwer-.5
Map/Parcel# Q 8y'
Address 1 s"T, S. Y♦,rk&V 711,
Lot#
Telephone# � -�j % �� 7% 76
Installer's Name -- $ our `p , y4%_ C ,
Designer's Name
Address 2-y 6recL e54a-f
h rO
Address
Telephone# 6q- q0.58
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.
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
DESCRIPTION OF�REPAIRS OR ALTERATIONS r' PO'c` (91 0( �lTfy P /
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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 laceUesystem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Z,oc r Date l - Z 2- I
No. DO 140C -iQ,-, '/44V ,'// FEE 16
COMMONWEALTH OF 1MASSACHUSTT
Board of Health, MA. V,
CERTIFICATE Of COMPLIANCE
Description of Work:. S(Individual Component(s) El Complete System b,
l )
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (V�, Upgraded ( ), Abandoned ( )
by: sh`� flt.�fi trrYt �,
at
has been installed ' acco •dance with the provisions of(,310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application ppNo. ®- � ` dated- — .Approved Design Flow "" (gpd)
Installer 1' V6,r—, 0V c (0 • ;Z-^6 _O_ _Q%
Designer: Inspector: ,. r C.�'(./ (✓ Date:
The issuance of this permit shall not be construed as a guars, a that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �V7G /�i�d MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE 0
oo99 )
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. . Ut'lr , dated / r
as described in the application for
Provided: Construction shall be completed within three years of the date of this p rn't- Ali local conditi ns must be met.
/ e !^
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date/ -' /' Board of Health / - �