HomeMy WebLinkAboutApp-Permit-ComplianceNo. JQ j'1DC48-4373(=0 FEE`Y 4-0'0
COMMONWEALTH OF MASSACHUSETTS
Board of Health, )k946400- J 14-
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(ve/upgradeO Abandon( 0 Complete System Individual Components
a s
ocation
OVAe
Owner's Name
Map/Parcel#
j` Z
Address
Lot# D
Telephone#
Installer's Name
Designer's Name
Address
9
���f^G i-wi
19
Address 93-3
M S/�'o✓
Telephone#
0 _ 0
Telephone* S
S .
Type of Building
Dwelling - No. of Bedrooms 2, r J
Other Type of Building
Other Fixtures
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers( ),Cafeteria(
Design Flow (min. required) gpd Calculated design flow Design flow provided gPd
Plan: Date 1" �/- �� Number of sheets It Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil E
DESCRIPTION OF REPAIRS OR ALTERATIONS �! f / jnPi d✓ J 4
Date of Evaluation /g
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed % �i/G Date O ��
Inspections
No. � � i C - � - �� /FEE
CO MONWEAL.T14 OF MASSACHUSETTS �
Board of Health, MA. F
CERTIFICATE OF COMPLIANCE
Description of Work: I<d Individual Component(s) ❑ Complete System ...
The' undersigned hereby certify that the Sewage Disposal System; Constructed ( )> Repaired ( ), Upgraded ( ), Abandoned O
�r Y
by GvSt' t �Yi
has been installed iu accordAnce with the provisions o;310 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No. - i, dated."7 " aA� 1� Approved Design Flow �(gpd)
Installer!' ' 'F✓ r.
Designer: Inspector; Date: r
The issuance of this permit shall not be construed as a,guairantee that the system will function as designed.
No. ,f?) ! P
7 COMMONWEALTH OF MASSAC USETTS
,trr
FEE
to
Board of Health, YA- 2 N6 J T1+ , MA.
DISPOSAL SYSTEM C®NSTRUCTIONT PERMIT
Permission is hereby granted to;, Co nstruct ) Repair( ' Upgrade Abandon ( ) an individual sewage disposal system
p
at b"e. as described in the application for
Av
Disposal System Construction Permit No. ' dated r f 1.
Provided: Construction shall be completed withi ii , o tl�date of this pepnitl .All local condition must be met..
4 �-,� fir._
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ~ Board of Health
7