HomeMy WebLinkAboutApp-Permit-ComplianceNo. VlJnc-400��� FEE , r�
COMMONWEALTH OF MASSAC14USETTS
Board of Health,G
APPLICATION
FORDISPOSAL SYSTEM CONSTRUCTION
PERMIT.
Application for a Permit to Construct( ) Repair (Jr/Upgrade( ) Abandon( ) - 0 Complete System 4ndividual Components
Location
Owner's Name ! -
Map/Parcel# r��
Address AtMWWAIJ0.�
Lot#
Telephone# ,' R• 93 �j 7
Installer's Namet t.ls� `
�' C Designer's edimazae C
.Address
0 22A
Address
OSS rj
93?
Telephone# 3, as
Telephone#Dif
r F
Type of Building Lot Size /0, 066 — sq. ft.
�e S c 5 �-+e, ] "�� 3 3 �- • Garbage grinder
Dwelling - No. of Bedrooms... _� g g (
Other - Type of Building, No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) d RQgpd Calculated design flow Design flow provided _ gPd
Plan: Date O'1 xiCNumber of sheets Revision Date
Title
Description ofSoil (s) f/1
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned a s install the above described Individual Sewage' Disposal System in accordance with the provisions of T= 5 and
further agree o not place the system in operation until a Certificate of Co pliancylias been issued by the Board of Health.
Signed Date /
No. g0R)C-l`6-0317 FEE ,00
IF- 2 COMMONWEALTH LTH OF MASSACHUSETTS
L _
Board of Health, r%/C1 , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: .� Individual Component(s) ❑ Complete System J/`to�ox
The undersigned
�hereeb�bl1ycertify that the Sewage Disposal System; Constructed ( ), Repaired, f Upgraded ( ), Abandoned ( )
by:1,-�� �OII r aid
�Sf X,,r A',nA �-l�l C.
at C2 1*129Qt1ser Z12Q
has been installed ill accordance with the provisions of, UO CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow _ (gpd)
Installer&r_46.
O C"
Designer: nspector: ) Date: 4.. _"< 4.
The issuance of this permit sh not be construed as a guard ee that the system will function as designed.
No. FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repair(fi') Upgrade ( ) Abandon( )An individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No ;` e' , dated
Provided: Construction shall be completed within dk44years of the date of this permit. All local conditions must be met..
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date `. _ s' Board of Health