HomeMy WebLinkAboutApp-Permit-ComplianceNo. bo #'VC45—Z(' ) v /{lAi(/ 14-'i 'i " � / / � 6 6 X FEE: � 6770
-76 COMMON LTH Of MASSACHUSETTS ck$#
Board of Health, �LAg&min- MA.
PPI LICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to .Construct( ) Repair( lade( ) Abandon( - ❑ Complete System J2 ndividual Components
Location
Owner's Name Ota
Map/Parcel#
—
Address _ e
Lot#
Telephone#
Installer's Name
e S
Designer's Name
Address!�/
ST l'Y1 D
Address
Telephone#
—
I Telephone#
Type of Building _ _ _ _ _ Lot Size sq. £t.
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 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1GY C _IaL�}}C IL 1,A// 150
The: undersigned agr to install the above described Individual SewageDisposal System;in accordance with the provisions. of TITLE 5 and
further agrees to to m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ Date _ 7�
Inspections.
No. O S C G.�oJ� FEE .) e�10
COMMONWEALTH OF MASSACHUSETTS - W 1115Board of Health, j nqa , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: dividual Component(s) ❑ Complete System
1470
The undersigne er y certify that tl-Sewa a Disposal System; Constructed ( )', Repaired HH'pgraded ( ), Abandoned ( ).
by P.+
at _
has been installed in accor a e with the provisions of 310 CMR 15.00 (Title 5) and the ;approveddesign plans/as-built plans relating to.
application No. d Wil%'- Approved Design Flow -- (gpd)
Installer
Designer: Inspector: Uf Date.:
The issuance of this permit shall not be construed as a gua _antee that the system will function as designed.
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No. �_ 1 `I�^, ^ 2jV:) (j FEE' I-7 �,g� v lJ
1./%
74 COMMONWEALTH LTH Of MASSACHUSETTS ��5�����a
Board of Health, ® t%n+ , MA.
DISPOSAL SYSTEM C STRUCTION PERMIT
Permission is hereby E�anted to Const uct( ) Repair( ) upgrade:( ) Abandon( ) an indi-vidual,sewage disposal system
at ��-�, D as described in the application for
Disposal System Construction Permit No/" 4''" %� dated -'7-" Zd
Provided: Construction shall be completed within three years of the. date of this per it All local co d" 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date__1 T /_d Board of Health l