HomeMy WebLinkAboutApp-Permit-ComplianceVVY /� r� h7� r t. Q, ( Y
ti h yNo. 04b [DC47-0312 lil✓ I I�--1 OV ��CJ 0 FEE
COMMONWEALTH OF MASSACHUSETTS
1363
Board of Health, MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( H/Complete System ❑ Individual Components
Location o A so .
Owner's Name iter
-W/166'
Map/Parcel# yo� a(j�
Address rJJ
Lot#
Telephone# eeJl ` 191g: A;1 1
Installer's Name
Designer's Name + 1
Address y�-�-►Id) a kw
Address t
Telephone# _ _-231-122
Telephone# -
Type of Building Lot Size �,��% sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder {
Other - Type of Building No. of persons Showers O,'Cafeteria
Other Fixtures
Design Flow (min. required) 33U gpd Calculated design flow Design flow provided 33G gpd
Plan Datel37l-zoo /s', �j0 Number of sheets Revision Date
Title ° i W -1U emsr
Description of SU1(s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to 't the above described Individual SewageDisposal System in accordance with the provisionsofTITLE 5 and
further agrees to not IaO the system in operation until Certificate of Compliance has been issued by the Board of Health.
Signed Date f'
Insnections
f
FEES
No. i
R COMMONWEALTH OF MASSACHUSETTS
Board of Health, y0,
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) * Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (Repaired( ), lTpgradedPAbandoned ( )
by: i—
r. m 7 -
has been installed in accordance with the provisions of S,],.Q CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. r fy dated d' ? �' ` :' Approved Design Flow. '� ' % " (gpd)
Installer r hF � r�) _
Designer: 3_ t Inspector: Date: C
The issuance of this permitshIll not be construed as a guarate that the system will function as designed.
No r P C.) s � 4 ': �. Z ` Y : *.l FEE,
COMMONWEALT14 Of MASSACHUSETTS
Board of Health,Yf-o MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(,,4 Repair( ) ;Upgrade (,) Abandon{ ) an individual sewage disposal system
at �l 4��, t , ; `, r <'r;k 1 .� r,� as described n the ap
,kplication for
Disposal System Construction Permit No. 7-- Z dated /0
Provided: Construction shall be completed within t e: date of this per -mi g All local conc_, dons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date % {: ?Board of Health
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