HomeMy WebLinkAboutApp-Permit-ComplianceNo ( ')Cf[i-t619 0/,< -
/�' )l COMMONWEALTH Of tASSACHUSETTS
FEE'` T -1d2)
ej
Board of Health, MA.
APPLICATIONO DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct. RepairO Upgrade( ) Abandon( - ❑ Complete System 0'1, dividual Components
Location (j - ✓✓1 7%
Owner's Name r d `
Map/Parcel# 3 �S�
Address
Lot#
Telephone#
Installer's Name ` �S� n o
Designer's Name
.Address Ct � 773114-0 9
Address
Telephone# .S'Og-
Telephone*
Type of Building GJrQe,.rr, Lot Size CoL4 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder*0
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS � ft 6� DY c u +.d=
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 ste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed19 / Date 1 �' oZ 9ra2�
Inspections
No,
FEE
kl COMMONWEALTH Off' MASSACHUSETTS
Board of Health, Y&eMOOTH , MA.
CERTIFICATE Of COMPLIANCE �t
Description of Work: Z.Kdividual Component(s) ❑ Complete System V
The undersigned hereby certify that the Sewage Dispotal System; Constructed ( ), Repaired ( ), Upgraded (—),-Abandoned O
at
�f
has been installed iiccordance with the prov ro s of 3 U CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. .� 21 , dated Approved Design Flow — (gpd)
Installer 5 C/Z- 4>..
Designer: Inspector:. Date: t s"
The issuance of this permit; shall not be construed as a,gua antee that the system will function as designed.
t.j
No. i(`i Tic - ! ( { FEE,U
COMMONWEALTH Of MASSACHUSETTS 7'
Board of Health, y�f 0 l%� , MA.
DISPOSAL. SYSTEM CONSTRUCTION _PERMIT
Permission is hereby granted to; Constru t( ) Repair( ) Upgrade( -1—Abandon( ) an individual sewage disposal system
at l.7 6 -_-� C✓r e" J, kll° , ') (-; as described in. the application for
Disposal System Construction Permit No. / -)-1 , dated /�; .� ilS
Provided: Construction shall be completed within three years of the date of y s erinit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date /_-)l Board of Heald l '
v