HomeMy WebLinkAboutApp-Permit-ComplianceNo. �p�{ �a O s--� FEE
COMMONWEALTH OF MASSACIeS S
Board of Health, � � ,�. , MA. /
APPLICATION FOP DISPOSAL SYSTEM STEM CONST#i UCTIO1V PERMIT
Application for a Permit to Construct( ) Repair(4pgrade( ) Abandon() - ❑ Complete System lli'individual Components
Location 37
h1ol 1-00
Owner's Name
i yr
Map/Parcel#
�i� ��
Address
Lot#
Telephone#
Installer's NameX-7,&Designer's
Name
Address
rAddress
114
M
Telephone#
D 61)-7/,Telephone#
7 X56P
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No.
a e
Name of Soil Evaluator K tS V1
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided 3 � � gpd
Revision 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 agrees to not to place the sys in operation until a Certificate of Compliarpce has been issued by the Board of Health.
Signed hg�� If Date
Inspections
No ��, - (t7`7 0 yY a p /,rff FEE
COMMONWEALTH Of I SSACHUSETTS A 7-iz-rb
Board of Health, Y&W 1) in MA.
,r CERTIFICATE Of COMPLIANCE
Description of Work: 1<+3Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Dilposal System; Constructed ( ), Repaired (, Upgraded ( ), AbandonedA d4 /r ( )
by:
has been installed inn.accor a ce with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.b "7/i dated. Approved Design Flow 3 �'� (gpd)
Installer r ea
i
, I': � -/ 4 e
Designer: ow ret' Inspector: / Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. b � " I��®�.. OS&Tn FEE �c
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COMMONWEALTH LTH ®F MASSACHUSETTS ch--l3s—
/ Board of Health,T /1111' , MA. ,v
DISPOSAL SYSTEM CONSTRUCTION TERMIT
Permission is hereby granted to; Construct( ) Repair(/) Upgrade( ) Abandon( ) an individual sewage disposal system
at % L410 o z, el as described in the application for
6 Disposal System Construction Permit No. — , dated ol
Provided: Construction shall be completed within t�f the date of this permit,,All ocal conditions must be met.
LForm 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date // Board of Heh �' J