HomeMy WebLinkAboutApp-Permit-ComplianceNo. 970yk e -- 385 k7L-D 1Z FEE
12e 9 COMNIO LTH Of MASSAC14USETTS G 246
Board of Health AR -/A b iii- MA
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' APPLICATION P DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - -P�mplete System ❑ Individual Components
Location V
Owner's Name
Map/Parcel#
Address eZI 0906/
Lot#
Telephone# LD G' 10O 7�
Installer's Name
Designer's Name
r
Address
Address
-�
Telephone# Ta �
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
k
No. of persons
Lot Size O (�� sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. requ' ed) CJ gpd Calculated design flow ?2 G Design flow provided cl J --Z gpd
Plan: Date 7 Number of sheets / Revision Date
Title
Description ofSoil(s)
Soil Evaluator Form No. Name of Soil Evaluator
SadIi4,*,Si 00-1-5 I b' (!'
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to place operation until a Certificate of , ompli ce has been issued by the Board of Health.
Signed Date /d--
Inspections -% �l s/
No. FEE raG" .s` FEE 0()
CO MONWEALT14 Of MASSAC14USETTS
Board of Health, MA. D 16,5/1 ck 7
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) O<,-;mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired( ), Upgraded ( ), Abandoned ( )
at 1/Z MA/Zi-W, Wk(t--- —
F'.G/�`r"C—. ...
has been installedin accordariisce wit - t
application No. / -7 , dated
Installer M24411
revisions &W16 Nf 15A'0 (Title 5) and the approved design plans/as-built plans relating to
Approved Design Flow 3(gpd)
Designer: FA)67AAQ;W�S7nspector: Date: n /
The issuance of this permit shall not be construed as a guarantee that the system will function as designed
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No. 1i bc-`""i 5' '.3 9
7
-rt-W y A.44-LXe—
COMMONWEALTH Of MASSACHUSETTS
Board of Health, )Lmm o J 4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE P ! 0. O'D
C k 2-98
0 elos-ll8 ok-, X19 7`
Permission is hereby granted to; Construct) Repair( ) Upgrade( ))Abandon( ) an individual sewage disposal system
at 42, !i' 494- tl! Ltk`'I f �'� iC? '7 /'0 as described in the application for
Disposal System Construction Permit No. �:7 /4' , dated -�
Providedp
3 1M :� Construction shall be completed within tljgg_v. ex's of the date of this p/i� �r'n tt /All local conditions must be met.
Form 1255 Rev. �9
�r.r Sulkin Co. Chadeslown, MA Date lyl� Bo rd of Health