HomeMy WebLinkAboutApp-Permit-ComplianceNo. &4DC48-2 oq vL TR - is -O() 40 r7o FEE
CO-14MONWEALTH OF MASSACHUSETTS
08280
Board of Health, ) q le&6 VTR MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( XUpgrade( ) Abandon( ') - is mplete System ❑ Individual Components
Location\V
Owner's Name
Map/Parcel# Z
Address tilp.C�} c)Z(j7
Lot#
Telephone#�
Installer's Name -
Designer's Name' ter` J Yi
Address `fit O �. �cW � mc�aZCoLI
Address --o n .. OZJ9141
�
�a� '� ,Q
Telephone# � -
Telephone# Cbc6 y- Cts
Type of Building\' cS \ (i�-tG 1 _ Lot Size i 0, (41 (o 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 Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees t thRperation
cribed Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further agrees to ac ie until a Certificate of Compliance h s been issued by the Board of Health.
Signed Date
Inspections
i..
No. FEE
�- COMMONWEALTH OF MASSACHUSETTS
>, Board of Health, )6ggBO OTU , MA.
W --
CERTIFICATE OF COMPLIANCE r ,o tS
t . 0a!
Description of Work: 0 wdi�duh`a�Component(s) CTComplete System
I
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The undersigned hereby certify that 'the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded^(Abandoned
at_T`FkC!"C"" tf `
has been installed in ccor ante with the provis' ns o 310 CMR 15.00 (Title 5) a d e pproved design plans/as-built plans relating to
application No., dated l . Approved Design Flow (gpd)
Installer 0 f)
Designer: ESI-, klyt-'7lL � 1 N), Inspector: gQp+ , Date:
The issuance of this permit; shall not be construed as a guarantee that the system will function as designed.
V O Z- _ FEE-
(
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ,4 6 Grr- - MA.
DISPOSAL SYSTEM CONSTRUCTION. PERMIT
Permission is hereby granted to; .Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at I I VA r N 1 as described in. the application for
Disposal System Construction Permit No. %r , dated
Provided: Construction shall be completed within three years of the date of this rt' _ All local conditions must be met..
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chdeslown, MA Date ' / ! 4 Board of Health
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