HomeMy WebLinkAboutApp-Permit-ComplianceNo. &wfz " I s . V V ` Wz, FEE iSy`Cfo
COMMONWEALTH OF MASSAC114USETTS 0,5-0
Board of Health, —tV, MA. �
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
pplication for Permit to Construct( ) Repair( ) Upgrad Abandon( ) - ❑ Complete System Q'rndividual Components
Location �')1�41 CM L&Kk
Owner's NameIj
Map/Parcel# 0
Address
Lot#
Telephone#
�1--
Installer's NameCR" owd
Designer's Name
Address t
Address
Telephone#
Telephone #
- (0900
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plait: Date
gpd Calculated design flow
Number of sheets
Title
Description of Sbil (s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
No. of persons
Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreto not to ace the tem in operation until a Certificate of Yom liance has been issued by the Board of Health.
Signed Date "1
COMMONWILALT14 OF MASSACHUSETTS
f �v
Beard o Health,
CERTIFICATE Of COMPLIANCE
Description of Work; In 'vdual Component(s) ❑ Complete System
The undersigned hereby certifythat the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedAbandoned ( )by: ELI Aat
has been stalled in accordange with the provisi ns of 310 CMR 15.00 (Title, 5) and the approved design plans/as-built plans relating to
application No. dated 7 Approved Design Flow (gpd)
Installer F l -
Designer: z( � 17W -E 1' - Inspector: Date:
The issuance of this permit shall not be construed as a guajr-Ardee that the system will function as designed.
No._ 1-%-Q" S -- -- �!t . `� `t e � l/C� jOJ� ".FEE _0
7 COMMONWEALTH OF MASSACHUSETTS
Board of Health, l FW k MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade /) Abandon( ) an individual sewage disposal system
7
of
at to !I1()% Ia.�h K t� V44 Ith illi as described in the application for
10/
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Disposal System Construction Permit No. r�-p
!—dated
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Provided: Construction shall be completed within.tia e .date of this permit All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ti - / Board of Health