HomeMy WebLinkAboutApp-Permit-ComplianceNo. -600c-ii-41BD3 Se CL t Tnn f<
-q j9-0 COMMONWEALTH Of MASSACHUSETTS
Board of Health,MA.
APPLICATION FOR L SYSTEM CONSTRUCTION
Application fora Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System V
JAN 15 2019
ALTH DEPT.
Components.
Location t55-1-1cG
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's NameGQ O
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Designer's, Name
Address p_ CJ_ X 6
Q �C.� �� d Lid/
Address
Telephone# Y0i) 750
W7 Z?? N
Telephone#
Type of Building �� Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided gpd
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 OR ALTERATIONS
The undersigns s to Inst a above d c ' dividu -Disposal System in accordance with the provisions of TITLE 5 and
further afire, to a nt�l a Certificate of lConpl' c has been issued by the Board of Health.
Signed Date
Inspections
No. i�7�� i C. �7 jQ ' FEE i.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �Y� � � MA. /A
actil' :t
CERTIFICATE OF COMPLIANCE �
Description of Work: Individual Component(s) ❑ Complete System
The undersigned herebyfcerti y that the S wage Disposal System; Constructed O, Repaired ( ; Upgraded ( ), Abandoned ( )
by: (-; ��C
at
has been installed in accordance with the provisio s o 3].0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /I I dated i . Approved Design Flow (gpd)
Installer Ulf),(t _L
Designer: Inspector:Date:
The issuance of this permit shall not be construed as a, guarantee that the system will function as designed.
,r� ,
No. �.``> T' {' - i r f r �'� 4 e!" f � c�1` s P FEE; 5,
COMMONWEALTH Of MASSACHUSETTS J� (%
Board of Healtlt., YqeM'01M4 MA.
ISP®L SYSTEM C NST�JCTI®l�T_.IT
Permission is herebygranted to Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at t '` as described in the application for
Disposal System Construction Permit No. /2-17 dated //Rh
.
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be rnet.
Form 1255 Rev. 5196A.M.,Sulkin Co. Chadeslown, MA Date —fi t `-� Board of Health
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