HomeMy WebLinkAboutApp-Permit-ComplianceNo.1500c— 6 L tj- (2— Zldv J21
118-0968 , 6 3 r /o = � bz�
COMMONW LTH OF MASSACHUSETTS
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Board of Health, � �- , MA.APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMI
Application fora Permit to Construct( ) Repair(-) Upgrade (,.YAbandon( ) Q'Complete System O Individual Components
LocationM
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name qc—
Designer's Name r
Address 15 4A�
Address
Telephone#
Telephone# _ *Oe �-
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures j C_'
Design Flow (min. required) �Q gpd Calculated design flow Design flow provided :3, Lid
Plan: Date Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ✓ti�t/JC��i
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 system in operation until a Certificate ofCormpliaiice has been issued by the Board of Health.
Signed Date
4 -
Inspections
i
No. �" ' --i.- 1 89 � FEE
COMMONWEALTH OF MASSACHUSETTS ��
Board of Health, ypa� n�� AIA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), UpgradedAbandoned ( }
has been installed in acor agce with the provisions of 310 CMR 15.00 (Title 5) and thea roved esign plans/as-built plans relating to
application No. I 4,-3 , dated /1_ `2/` /-,9 . Approved Design Flow rd)
Installer TA �-i 0 _ A,&) -r >-�/.! ?Y- w 4rA l -
Designer: &J"JA tA tai 1'Cn 1> 1 iii Inspector: '� 7 .-J i Date:
The issuance of this permitshall not. be construed as a guar tee that the system will function as designed.
No.—t""��G.1 "6 ftti�C� �. i f�—t"i`i FEE'.,a��}
COMMONWEALTH Of MASSACHUSETTS 4 (0 Z,
Board of Health, Q , Am.
DISPOSAL SYSTEM CONSTRUCTION` -PERMIT
Permission is hereby granted to; Construct( ) Repair( ) UpgradeA Abandon( ) an individual sewage disposal system
at ' ,� ( / .,described in the application for
w. n e r
Disposal System Cotruction Permit No.� dated`
.Provided:. Construction shall be completed within t �t■sof the. date of thispermit. All local conditions must be met.
-; / �y
Form 1255 Rev. 5/96 A.M.Sulkin Co. Chadeslown, MA Date "Board of Health ,
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