HomeMy WebLinkAboutApp-Permit-ComplianceNo. 800C-47-0088 if uD J z, — 16-6002-0 FEE y�
t7,-�t� COMMONWEALTH LTH ®F MASSACHUSETTS
Board of Health, V NU�0 QTIN MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairv,-Upgrade( ) Abandon( - dComplete System ❑ Individual Components
Location S e fY�9 n
Owner's Name
Map/Parcel# .3 iRt SA
Address
Lot#
Telephone#
Installer's Name (..I
Designer's Name��
/
Address `` -3 ci wt �- .! t
Address I>, 0 a ( V
Telephone#
Telephone# SbL73b
Type of Building V joQ SX- Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder M0
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 :7 l i Number of sheets Revision Date
Title
Description of Sbil(s) 0A1p�-;tom. g r,r j
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONSc� 25C�hc►Pt]Q��
1-1 [fl ride ot%x Q �Sa( Q r w lr, r i..v4N—%,t.r�5 W
ka,i)c 33 x ) VA cx&-f
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 x _ Date
" Inspections
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YAP= M iJ QT" , MA.
CERTIFICATE Of COMPLIANCE
FEE 00
. 9LS
Description of Work: ❑ Individual Component(s) ff Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired%(/), Upgraded ( ), Abandoned ( )
by: :S c t 1 k CIA *Vt-r.d1�A,...
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5)and the proved design plans/as-built plans relating to
application No. �+ " �" dated Approved Design Flow (gpd)
Installer
Designer: T4nC, t.e. kA. tE I Inspector: /! ,4" ' Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. r
No. 60n p t-•,
i 1 �2 - 00 8,9 H, , T"� tnwr— FEE 4 1<
COMMONWEALTH Of MASSACHUSETTS
Board (f Health, yAgk-,A n Ln-%- _ __ __ -, MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(v'� Upgrade ( ) Aban4on( ) an individual sewage disposal system
at &�! kk mu p, r- joeS � as described in the application for
Disposal System Construction Permit No. �r� dated `
Provided: Construction shall be completed within tf the date of this perrqiAll local conditions must be met.
BAkzForm 1255 Rev. 5/96 A.M. Sulkin Co, Chadeslown, MA Date '��—/Board of Health