HomeMy WebLinkAboutApp-Permit-ComplianceNo. g00 c-17- ob R 9
� 2 Board of Health, y"AgmDUT14 MA.
FEE .�
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrade
andonO - omplete System ❑Individual Components
Location 1' vi
iiA VA ft,
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name 6tA&
r
Designer's Name
Address JO 1Q1VA41))AP
Address nK
Telephone#
Telephone! ---5-0
O-,33 11
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms / �� Garbage grinder ( )
Other - Type ofBuilding No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) '� gpd Calculated design flow Design flow provided gpd
Plait: Date Number of sheets Revision Date
Title
Description ofSbil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre s to not to lace the system in operation until a Certificate of C..,,omjjp��liance has been issued by the Board of Health.
Signed Date �L-
� ! 11
Inspections
EE SY, 00
-70
COMMONWEALTH OF MASSACHOSETTTSaA q- /-
Board of Deal#t1 O f3 , MA. L''' i4 �1
VA ;--
CERTIFICATE OF COMPLIANCE6
Description of Work: ❑ Individual Component(s) to System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (andoned (')
at )
has been installed in accordance with the provisions of 310 C5.00 (Title 5) and thea proved design plans/as-built plans relating to
M
application No. dated S "l Approved Design Flow f. (gpd)
Installer_y�it't flAA14 tkP1,-kA
Designer: "i Inspectors 3C :_2%C,e'" t'r Date: 7
The issuance oft is permit shall not be construed as a
'Far ant a that the system will function as designed.
COMMONWEALTH OF MASSAC14US ETTS
Board of.Health, N-aL M:�` , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
�Pcd�r�y
Permission is herebygranted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 2(/,1 ( a ' A , A10M f as described in the application for
Disposal System Construction Permit No. dated?— 7--f
�.
Provided: Construction shall be completed within three years of the date of this perm/?t. All local con ' 'ons must be met.
Form 1255 Rev; 5/96�A.M. Sulkin Co. Chadestown,MA ,r Date F- -1 Boar7d of Health
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