HomeMy WebLinkAboutApp-Permit-ComplianceNo.. DGs-2,0�/Z, X -1� Z/ la
-AP COMMONWEALTH OF MASSACHUSETTS
Board of Health, YA'1-�-,i 81fi-W , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERM11
FEE4 451
cyto t 4
Application fora Permit to Construct( ) Repairk Upgrade( ) Abandon( - ❑ Complete System *Individual Components
Location
8 l.;ft �-
Owner's Name
Map/Parcel#
Address as 2 ie�L ps C1 (/I, t..
Lot#
Telephone#
Installer's Name 1. • .e
Designer's Name AJL4
Address C�
d f
Address _
Telephone#
Dir 7SS 77
Telephone#
Type of Building R"ES 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)
Plan: Date
Title
Description ofSbil(s) _
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �S14U,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre s to o place the system in operation until Certificate of Compliance has been issued by the Board of Health.
Signed — DaterJ ' 3
Inspections
,? .. ;�, 1_ FEE SS, 00
No. - ,= COMMONWEALTH LTH OF MASSACHUSETTS Ne 00
Board of Health, Y"M/l t) ,
�� �\Io ;
CERTIFICATE Of COMPLIANCE' off` I
Description of Work: Individual Component(s), O Complete System 4�,
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded ( ), Abandoned
at � �
has been installed ' -i accorda ce with t e provisions of 3 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application 1k, _ /.0 � , dated � -� Approved Design Flow d
PP � � � /P
PP g (gpd)
Installer CA&C--i,A7)t� �&JX??V—,DA_4' _1 Pi(3% 3
Designer:Inspector:
The issuance of thispermit hall not be construed as a guarantee that tl
No. � i ' (.i ,. r A FEE t�?µ1CJQJ
COMMONWEALTH Of MASSACHUSETTS rJ- io (,I
Board of Healt{t, Y/hf , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission ishereby granted to; Construct( ) Repair(lj Upgrade( ) Abandon( ) an individual; sewage disposal system
at
Disposal System Construction Permit No. ihJ , dated �!
as described in. the. application for
Provided: Construction shall be completed within three years of the date of this peEj:pit 11 local conditions must met.
" % .y
Form 1255 Rev. 5/96 A.M. Sulkin Go. Chadeslown, MA Date "r pard of Health. J� ��� - ' / ��✓
-r