HomeMy WebLinkAboutApp-Permit-ComplianceNo. /�/FEE
LO ��fL L�� y V
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YA-P- V1.0jg i MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ❑ Complete System Individual Components
Location
[-f CCU6 e -1p,
Owner's Name W.44:7 -EPL-
Map/Parcel#
149 o
Address P61) 00K
Lot#
Telephone#
Installer's Name®
Designer's Name A
Address
tsL�'
Address
Telephone#
S62 r-99-'77 7
Telephone#
Type of Building pe D601-7 A -c- 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
Plan: Date Number of sheets Revision Date
Title
Description of Sbil(s)
Soil Evaluator Form No. Name of Soil Evaluator 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 agrees to ry1f-t-4lac5jhe system in; operation until a Certificate of Compliance has been issued by the Board of health.
Signed Date --5 - xq" Is
Inspections
im
No. (, .( U,(--( �,'IC� FEE a;
COMMONWEALTH OF MASSACHUSETTS
Board of Healtli, �PgN lljT-VA , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: "dividual Component(s) ❑ Complete System +
51'/x/ /�
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired 0(), Upgraded {) A andoned
by /E
at v,
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ,� dated _�2 Approved Design Flow (gpd)
Installer a
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a garx1fe that the system will function as designed.
No. boo DC i7-- � 1.�"� (1 � 1
CA 16th C -;-N i2 f I� iv FEE. " C)C,
COMMONWEALTH Of MASSACHUSETTS ck* ( U4
Board of Health,��} t ru MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to Construct( ) Repair(%1 Upgrade ( ) Abandon( ) an individual; sewage disposal system
at 1 i as described in. the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this Derinit. All local conditions must be :met.
Form 1255 Rev. 5/96 A.M."Sulkin Co. Chadeslown, MA Date � � Board of Health