HomeMy WebLinkAboutApp-Permit-ComplianceNo. � � LV[V,-j s- 6n635- FEE
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ONWEALTH Of MASSACHUSETTS c.Qri- 00
a �i�� C f Board of Health, O , MA.
J A CA I®N FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct() Repair( ) Upgrade( ) Abandon() - 0 Complete System O Individual Components
Location se
Owner's Name 7 j4 , / I all r
Map/Parcel# 17 ! f
Address % 5- j 4, 5e -A iQ v Q
Lot#d, ATelephone#
� � _ . 'Zl�7' An m�
Installer's Name d A 0—o w'-Skn tot4
Designer's Name 17jn Ql 0e;i, sS ,
Address Po box a3 -r- Bnews vnA02631
Address PO 773 134BW5 Lk vr1i4 0261
Telephone# _j�, 7-713
Telephone# — g 6aL r
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Lot Size 1 % 1 e
We) sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) CSU gpd Calculated design flower Design flow provided gpd
Plan: Date _/.0 /J& 7 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
The undersignedagree to install the a ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of place the sysVin in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date __( , %
Inspections '�� 1k
y
EE
COMMON LTII OF MASSACRUSETT, ' , v ` e bo�i
aoard of Health, Kn1 7 N ; MA. t
CERTIF!�ATE Or COMPLIANCE
Description of Work: 0 Individual Component(s) 0 Complete System
The undersigned hereby cerAfy that the Sew�ge Disposal System; Constructed (Repaired ( ), UpgradedK)Abandoned ( )
by:
at
has been
with
10 CMR 15.00 (Title 5)
desig plans/ass Ylt plaTeLa
Installer ' ' W ' 17 ' W1
IV
} Ci
Designer: Inspector: X*' -,ZkcWJ11 Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
WA
No. "l.. ii V � f `�J13�� �ii; .'�ii� i\S� FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YA%Z M 0/13 , MA.
DISPOSAL SYSTEM C®NSTRUC , ON PERMIT
Permission is l,Sreby granted to; Construct( ) Repair( ) Upgrade ) Abandon ( ) an individual sewage disposal system
at
io cu
as described in the application for
Disposal System Construction Permit No. / —� / ? , dated / / -,2
Provided: Construction shall be completed withirL hxee- e'ar the date of this permit, All local conditiOf�s must be met.
Form/1255 R v. 5/96/A.M. Sulkin Co. Chad eC$town, MA JjDate B yoard of Health
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