HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH Of MASS CHUSETTS &j#,3 q 4
X� Board of fIealth, °Aouyv , MA.
✓ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMITS 4,
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon O - ❑ Complete System n vidual Components
Location 3 Tsn b lM ,—,L;�-
Owner's Name/0e)-e--
-el, JY5,))j
Map/Parcel# 030,97
Address aO-2&- /--.3 r
c/ /9 V Cs -e n
Lot#
Telephone# Cji 2®- 3.30` & x'52
Installer's Name ; {t �U COQ
Designer's Name2Oh1 )0
Address a` 3 I z
Address
O
Telephone#
Tlephone# 4 o -
Type of Buildingff%'N'
Dwelling - No. of Bedrooms
Other -Type of Building No. of persons
Other Fixtures
Design Flow (mina required'
Plan: Date ►'►'14}4
Title
Description of Sbil(s) _
Soil Evaluator Form No.
SQ
Lot Size
sq. ft.
Garbage grinder { )
Showers ( ), Cafeteria ( )
I gpd Calculated design flow 46( Design flow provided
Number of sheets 1 Revision Date
G
Name of Soil Evaluator )C/j' eltI114 e- Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S ee See, AQ -PS) ;,C �Q
gpd
The undersigned agrees to ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to ce s e r lfSn until a Certificate of CComplianc has been issued by the Board of Health.
Signed Date J 1
Inspections b " �� 7 gz� e9k -
No. C — 1-7 cl
COMMONWEALTH OF MASSACHUSETTS
FEEa
Board of Health, --� MA.
CERTIFICATE Of COMPLIANCE /
Description of Work:l<lidual Component(s) ❑ Complete System.
The undersigned hereby, certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded, ( ), Abandoned l }
at21
has been instal]
application No.
Installer i-
r�
with the provisions of 310 CMR 15.00 (Title 5) arfd the a tproved design plans/as-built plans relating to
dated, 'Z7Approved Design Flow Z (gpd)
Designer: R""n i t 4kZ1 l t C P C_ Inspector: .1;�f r -4!V I Date: 41
The issuance of this permit J% not be constru4l as a guarantee' a that the system will function as designed.
No. Eo iA 1c-1-7�° 77
I f COMMONWEALTH OF MASSACHUSETTS
Board of Health, ��}(eA-( ET:1A MA.
` � DISPOSAL SYSTEM CONSTRUCTION PERMIT
-2 / `,
FEE '5 7�r
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Permission is hereby granted to; Construct( ) Repair( ) Upgrade(I abandon ( ) an individual sewage disposal system
at r-�, -L ,ACI !w "cC. i/) � t 1�: to i i �-_i�; r v,, C"T1 1 as described in the application for
i t V
Disposal System Construction Permit No. %�, dated
Provided: Construction shall be compleEL-d within•.Ib�s off thFd-ate of this permit. All local con 'tions must be met. _
Form 125YRev. 5/96 A.M.SulkinCo. Chadeslown,MA Date/ Board ofHealth
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