HomeMy WebLinkAboutApp-Permit-ComplianceNo. Q ^W'28S/ ,ill F?1
JC � l ��6 -I COMMONWEALTH ®F MASSACHUSETTS If G ��� �a
f ) o� MA.
Board o Health, ,
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` APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
JAp lication for a Permit to Construct( ) Repairj[) Upgrade() Abandon() -
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ElComplete System 9iidividual Components
cation
CrOtilOwner'sName
c `(- 4 i `�cxp/Parcel#
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Address // R GS S
Lot#
(o
Telephone# S0 g — 771-3 7 3q
Installer's Name
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�- 60. ANC,
Designer's Name
Address
Address
Telephone# S
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other- Type of Building 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 of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned s to install the above describe dividual Sewage Dispo al S stem in accordance with the provisions of TITLE 5 and
further agr n a%c "ttie system in oper until a Certificate of C pl' ce has been issued by the Board of Health.
Signed Date
Inspections
FEE
Board of Health, , MA. all
1 ,
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired N<Upgraded ( ), Abandoned ( )
by: _
at
has been installed ' accordance with the rovi ons o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �. 7 dated . Approved Design Flow'`" (gpd)
Installer 2T
Designer: Inspector:_/�,y,i _ Date: e.9%
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. '`1 C-1 2 "2_E')6q d� Q FEE
Pr 77 COMMON�LT14®f MASSACHUSETTS - ooeeLID
Board of Health, 0 0174 MA.
DISPOSAL SYSTEM CONSTRUCTION ]PERMIT
Permission is hereby granted to; Construct( ) Repair(V'f Upgrade( ) Abandon( ) an individual sewage disposal system
at 4 4e, Z8 4t_6401%. f &ir"� as described in the application for
Disposal System Construction Permit No. l dated r
Provided: Construction shall be completed within three years of the date of this pe i 411 local condkWns must be met.
Form 1255 Rev.5/96 A.M. Sulkin Co. ChMeslown,MA Date 7&Board of Health f 3er G i