HomeMy WebLinkAboutApp-Permit-ComplianceNo. b F W T/L'" V3 Q() 55Z) FEE'; �S7�.
I foe COMMONWEALTH Of MASSAC14USETTS
Board of Health,MA.
IP PLICATION .FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - Q.G�Mplete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# ._ _
Address
Lot#
Telephone#
ot
Installer's Name (
Designer's Name I ?1S CQ
Address 0
Address
Telephone#
Telephone#
Type of Building' vt _ Lot Size J 7"v fsq, ft
Dwelling -No. of Bedrooms c5 _ 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 Date of Evaluation
t
DESCRIPTION OF REPAIRS: OR ALTERATIONS
d
r -
The. undersigned a -,-Ie s to install the above described Individual Sewage Disposal System.in accordance with the provisions. of TITLE 5 and,
further agrees op tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed,Date. t�-—
Inspections.
No. FEE. �2Q�0
/1 C C®MMONW LTI-I Of MASSACHUSETTS
Board of Health; 74►ROnA, MA.
CERTIFICATE OF COMPLIANCE
Description of Work:, ❑ Individual Components) Complete System
The undersigned herebyrtify that the Sewag7 Disposal System; Constructed( ).,.Repaired ( ); Upgraded (C iandoned ( ).
by:
at
has been installed' ccordax}ce with the rovisions o 310 CMR 15.00 (Title 5) ai d t approved design plans/as-built .p_ans relating to
application No. 10'" dated .�- ^f Approved Design Flow }"�(gpd)
Installer €
Designer: Inspector:; Date:
The issuance of this permit shall not be construed as a gnarntee that the system will function as designed.
No. .C-�(�"Iv FEE_,1` t�G
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COMMONWEALTH LTH Of MASSACHUSETTS ck-* 7 8 040
Board of Health, yplig: Yl®i%n , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to ; Construct( ) Repair( ) upgrade ( Abandon( ) an individual, sewage disposal system
at. _ `� 33o� x- e7 .. as described in the application for
Disposal System Construction Permit No.dated 1
Provided: Construction shall be completed withhi di rs othe; date of this permit.. Alli local conditions must be met.
Form 1255 Rev. 5196; A.M. Sulkin Co. Chadestown, MA Date -2 Board of Health