HomeMy WebLinkAboutApp-Permit-ComplianceNo. . 0D C^L 9—CoUS% FEE
7 C®MMONWLTI4 Of MASSACITUSETTS e1
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Board of Health, Wmn MA.
APPLICATION FOR IS/Upg,
SAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair rade Abandon - 0 Com lete S tem°O Individal Com . orients
() P () () P System
P
Location + \
Owner's Name
r�
Map/Parcel# (� ��
Address �l (� ,IST L62 _
Lot#
Telephone#
Installer's Name f1V ..,.1D
Designer's Name
Address 14
Address
Telephone# 5 D - 4 _
Telephone#
Type of Building ��� P 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
DESCRIPTION OF REPAIRS OR
/92144n -PVI. c
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further,agMito place(6e)systen)nin operation until a Certificate of Compliabce has been issued by the Board of Health..
Signed Date A�2-� ( b
No. FEE r
COMMONWEALTH OF MASSACHUSETTS # �,. T0,L
Board of Health, I i4lem (-W
CERTIFICATE OF COMPLIANCE kl"
Description of Work: y0vidual Component) O Complete System
The undersi 11 hereby certify that the Sewage Disposal System; Constructed O, Repaired ( }, Upgraded ( ), Abandoned ( )'
by R \ t 14 L 8\jrL 0r i
at qt,, i l i F'(G; k C7 \ rl i" -riot,
has been installed i/n� accordance with theirovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicationN,9., X — dated 3�i - ; Approved Design Flow --- (gpd)
Installer- ( {% 1 UI)V
`` /r.
Designer: /\. 1 A Inspector:. Date: f . The issuance of this permit shall not be construed as a, ga;r tee that the system will function as designed.
No. O�4�C' C �$ S^ FEE'7 �, U
i
COMMONWEALTH OF MASSACHUSETTS �� rU-4 7ov�
Board of Health, i MA.
DISPOSAL SYSTEM CONSTRUCTION -,HERMIT
Permission is hereby granted to; Construct( ) RepairL,)-,'6pgrade ( ) Abandon( ) an individual sewage disposal system
at �4 LIA i L -f ! ru i i 1 i J t Y' \ as described in the application for
Disposal System Construction Permit No.//8"- 1-:7�7 , dated
Provided: Construction shall be completed within three years of the date of this permitl local conditi s must be met.
Form 1255 Rev. 5/96 A,Mf'Sglkin Co. ChaBeslewn, MA Date Board of Health f
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