HomeMy WebLinkAboutApp-Permit-ComplianceNo. {7 Y _TFV` — 17— V ® 5-9fo FEE
CO-14MONWEALTII OF MASSACHUSETTS �
BoardofHealth, V OjTg MA. APR 10 Z018
APPLICATION FOR ISPOSAL SYSTEM CONSTRUCTION PE IT
HEALTH DEP
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System O hidivi u oinponeriis'__-
Location I
/ �`
Owner's Name /
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Map/Parcel#
6(o0 i
Address /
/�i/7` p.
Lot#
Telephone#
-
iristaller's Nam
Designer's Name
USX%
Address
r'J �!�>
Address
Telephone#
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Telephone#
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Type of Building 61(1 Cr� b� ' r� ! / Lot Size sq. ft,
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) '�C% j% gpd Calculated design flow 4 d Design flow provided 1g gpd
Plan: Date ��'J � , -ZO) 7 Number of sheets /' Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS > �-
The undersigned a es to' all the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre to t t `plac the system in operation until a Certificate ofo pliance has been issued by the Board of Health.
Signed � Date 1 � %
Inspections
77/1
y.
'%//X// Yi CC 11- Q lzr r,*Ie �
No. 117y FEE t� Q
Board of Health )L4&°M0Lr i+ , MA.
CERTIFICATE Of COMPLIANCE key
Description of Work:: ❑ Individual Component(s) O Complete System
The undersigned hereby certif that the Sewage Dispos ystem; Consti a ed ( ), Repaired ( ) , Upgraded Q Abandoned(
by:
at
has been installed i i acco dance with thof10 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No. _ % dated =" /� Approved Design Flow gpd)
Installer ^Ai4 P bfry...
Designer: Inspector: Date: f
The issuance of this permit shall not be .construed as a guarantee that the system will,function as designed.
il�C t/i�'j�iE�lii`d��i�—a FEE
No.L
COMMONWEALTH Of MASSACHUSETTS
Board of Health,�t-i�-Nidi) i'4 - MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby anted to Construct Repair( ) Upgrade O Abandon( ) an individual sewage disposal system
at % �% C / "� j�f ,12 m ' ") as described in the application for
Disposal System Construction Permit No.' dated:
Provided: Construction shall be completed withi tlr e� f the date of this perm,4, All local condi ' ns must be met..
Board of Health
Forts 1255 Rev: 5196 A.M. Sulkin Co. Chadestown, �Date .MA