HomeMy WebLinkAboutApp-Permit-ComplianceNo.�'//e' f��� FEE'
/ � f 7d COMMONWEALTH Of MASSACHUSETTS A � 3
Board of Health, V4qV1'i'i'0UTV , MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRTI T
Application for a Permit to Construct( ) Repair( ) Upgrade(ij'**AbandonO - ❑ Complete System GYidividual Components
Location C
Owner's Name e
Map/Parcel#
Address j
Lot#
Telephone# 11 '] G
Installer's Names( --�
Designer's Name
Address
-
Address i G -'
Telephone# G�n-
Telephone# t
Type of Building r-- Lot Size \0 sq. ft:
Dwelling - No. of Bedrooms Garbage grinder {
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtlwec
Design Flow (min. required) 1 3 CD gpd Calculated design flow Design flow provided Yd-- gpd
Plan: Date S `Q k ! Number of sheets Revision Date
Title
Description of 5oii(s)
Soil Evaluator Form No,
Name of.SoilEvaluator , °mctVKKk� Date of Evaluation 'f'Y\a1%TQ e n
-tilt
Lom
DESCRIPTION OF REPAIRS OR ALTERATIONS + -+. - 4.1 41\(3wQ :'—IM, Cc-A.Az�r.\ WVN
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 place the s m in operation until a Certificate of'Compliance has been issued by the: Board of Health.
Signed j Date of 7 IE?
No. ) �+��� , �a / • FEE
COMMONWEALTH OF MASS CHUSETTS
Board of Health, AM _
CERTIFICATE OF COMPLIANCE
Description of Work: aldividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Reparre /),,�tp-x,aded(V)-,Alai idoned
by: �" a ► 6`�a ® "ems" 1� C +� , , i b �n
at CFc)
has been installed iq accordance with the rovisions of l0 CMR 15.00:. (Title 5) and th a proved design plans/as-built plans relating to
application No. I� �_;f_ dated Approved Design Flow (gpd)
Installer
Designer: 5 �. r+: e .S C SVL J- lnspector: g4g Date:
The issuance of this permit shall not be construed as a guarar .e that the ystem will function as designed.
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No. ' s tip /� <Y�'�i � u #�x> � FEE, Qf,�
COMMONWEALTH OF MASSACHUSETTS ci
Board of Health, V mQ In ,VIA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission ishereby granted to Construct( ) Repair( ) Upgrade( Lf Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. dated s_
as described in. the application for
Provided: Construction shall be completed within three years of the date of this permi . All local conditions must be met.
Form1255 Rev.5/96 A.M.,SulkinCo. Chadeslown,MA Date /� - '� /CTBoard of Health f