HomeMy WebLinkAboutApp-Permit-ComplianceNo. {bo�\ $FEE16510 0
/9 _0 COMMONWEALTH OF MASSACHUSETTS c&Vb8g
Board of llealth, _ YMMOUTH , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( 'Upgrade O Abandon( ❑ Complete System )(Individual Components
Location
b Ax-jAsOwner's
Name TO AN
Map/Parcel#
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Address (L0AAM S P 'T74 WV.
Lot#
Telephone#
Installer's Name�
P E vut € l:. -
S Designer's Name Ail
Address
Address
Telephone#
• o2 —qT7 7 r 99-7
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 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of.Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
1i SCJ k4-(
LO
The undersigned agrees to install the above described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further agrees to 0 o pl ce the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 2-- U . _ "XO LSZ
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, /A RMOM MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired {, Upgraded ( ), Abandoned ( )
..•e a .� -
at 14 h 4iVA S I?A--IV-(
has been installed in accordance with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. s t! dated . Approved Design Flow (gpd)
Installer i (:—::-tQ79kPAj.DE_s'`� t 4IS'kt-t\ � R4� (� i7F-� b lit)R
Designer: Inspector:4 ( �w Date:
The issuance of this permit shall not be construed as a,guarantthat the system will function as designed.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YAAM® , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE 00.
Permission is hereby granted to; Construct( ) Repair(A Upgrade( ) Abandon( ) an individual sewage disposal system
at A)AS PA as described in. the application for
Disposal System Construction Permit No. / E3 -- dated /
Provided: Construction shall be completed within three years of the date of this perrnit��',.'Al local conditions g ust be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown,MA Date .f`Board of Health
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