HomeMy WebLinkAboutApp-Permit-ComplianceNo. f) � r' cA IY0O5Z /�;7 % j � lz'— �— if 7' V V
FE.E
90
COMMONWEALTH Of MASSACHUSETTS ,OL
Board of Health, Y� MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
A;" aApp cation for a Permit to Construct( ) Repair V<Upgrade Abandon( - ❑ Complete System Znl ividual Components.
L cation ! '�f / �C���r'✓ �% Owner's Name 61A1
Map/Parcel# y
_
Address lAfl
Lot# �L'
Telephone#
Installer's Name
Designer's Name
Address �/f !/ e�eddvr� R� �' QQ,��sr �'
Address
Telephone# Q r O9
Telephone#
Type of Building Re Lot Size J7 3 sq. ft.
Dwelling- No. of Bedrooms Garbage grinder { )
Other - Tv
pe of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design. Flow (min. required) gpd Calculated design flow Design flow provided --�1J / gPa
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisionsofTITLE 5 and
further agree t t to acce�e system in operation until a Certificate of m Y iance has been issued b the Board of Health.
SignedGv/�Date
r" Inspections
(} 88 G� ; ('�� FEE 0
No. �S "C r �''
Board of Health, Nl 0 t M-% , MA.
CERTIFICATE Of COMPLIANCE '
Description of Work: "dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned
i
has been installed in ccor nce with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated. " 7�l,$ . ApprovedDesign Flow "'"" ' (gpd)
Installer rim ✓.�sx,�.f�� r' J='r r�•v'� /�i i� f'1
Designer: "'"" Inspector: _ �� )4" 1,&AfZ Date: �v
The issuance of this permit shall not be construed as a, gua ee that the system will function as designed.
Board of Health, TP&&kOL :-c MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
6
FEE' `
-000 D
Permission is hereby granted to; Construct( ) Repair(-J'�Upgrade ( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. / lk", dated l =/ Y
Provided: Construction shall be completed within three years of the date of this pert it. All local condition#must be met.
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Form1255 Rev.5/96 A.M.,SulkinGo. Chadeslown,MA Date lKt3oard of Health ✓ Gr