HomeMy WebLinkAboutApp-Permit-ComplianceNo. �t�"'I?M�. FEE
COMMONWEALTH Of MASSACHUSETTS GW a3 I
Board of Health, YIqJ2ffiQL N , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair (epgradeA Abandon( - ®'Complete System ❑ Individual Components
Location �` f/� �'j'- ye,
Owner's Name
Map/Parcel#
Address ` r .4 ,W e
Lot#
Telephone#I 7 �e
Installer's Name O%' y%% �r '� /
Designer's Name
Address
Address
Telephone#��' �' ,a/�
Telephone#
Type of Building �Z <-`P
Dwelling - No. of Bedrooms o�
Other - Type of Building
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ® gpd Calculated design flow 'Z 01 Design flow provided IZF gpd
Plan: Date ""G —p Ir" ; Number of sheets / Revision Date
Title
Description ofSoil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ) Date /ep
Inspections
No.. 4�( ^ ice- 14 �' FEE Cs
C®�l MON�I,TII OF MASSACHUSETTS �-�
Board of Health, ?i fi , MA
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 4 Com��++''plete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: I�"�i ri9 ° �"�ss��d✓.�" P�*Ot%;3T �I" C ")
at Ve-711
has been installed in accordai ith the provisio of 31 CMR 15.00 (Title 5) and t proved design plans/as-built plans relating to
application No. '� dated (0 Approved Design Flow (gpd)
Installer �X--',O" .e'' Cb°" C? % '�
Designer: �j.i`c' /ht .i�, Inspector: r'' 1 Date: $ !
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. ? -t �� �t3 ��`� �,j t . !_ )' t� C% 3,orpcCSvc FEE .
4. COMMONWEALT14 Of MASSACIIUSETTS JLq 0;�, �
Board of Health,m 1? U ! TT , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade ( Abandon( ) an individual sewage disposal system
at 4:r' 15: 1::X d A�-'4r dam' „�d1�� , as described in the application for
Disposal System Construction Permit No. , :e- fm " , dated
Provided: Construction shall be completed within tweed' th' d to of this perTit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chade*wn, MA Date/O, r�4 ' .t'�, Board of Health � �'