HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1� �(/W rYc-�.. FEE 6& 6
f� X/ COMMONWEALTH OF MASC USET S
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade Abandon( omplete System 0 Individual Components
Location
Owner's Name
Map/Parcel# I00
Address 2 0
Lot#
Telephone#
Installer'sName
Designer'sName
Address
Address
Telephone# p _ ���,
Telephone# sp
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
Plan: Date -C /4 V,?evV Number of sheets Revision Date
Title
Description of Sbil(s) �
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
/ "T�- ,r^ /s r
DESCRIPTION OF REPAIRS OR ALTERATIONS 4506y 6�<-& V &Z
The undersigned a es to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t to place a tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Y -,A E4 �
s
Inspec
No.
FEE
Jf� COQ' MONWEAL114 OF MASSACHUSETTS � 0
r ,�� MA. J� C
Board of Health, �I A �y � , /
CE TIFICATi OF COMPLIANCE �' � � g
Description of Work: D Individual Component(s), Q..Gomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired ( ), UpgradedAbandoned O`
by: .11�l -
'3t r.�..�
has been installed in accordan e with the revisions of 3J Q CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �— dated '' ,� . Approved Design Flow (gpd)
Installer.'9!
Designer:9- Inspector:.etre'`,-g Date:
The issuance of this permit shall not be co trued as a guarantee'that the system will function as designed.
No. —�� j�� (d 7 1 1 " d' FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, (10n} MA.
DISPOSAL SYSTEM CONSTRUCTIONPERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( !Abandon( ) an individual, sewage disposal system
at_j if ��a�rt•_�/� as described in the application for
Disposal System Construction Permit No. '" I f , dated
Provided: Construction shall be completed within three years of the date of this in All local onditions must be met.
Form 1255 Rev. 5/96 A.M.,Sulkin Co. ChadWown, MA Date Board of Health Ole
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