HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF iiiASSACHUSE-T 'S
Board tfFleallh, YAAf2t 00 114 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSYRUCTION
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lication for a Permit to Construct e airair(� Upgrade( tde Abandon - O Com Tete S sten
SPP (�� . /) Pg't O O P Y
6�ew
Axa
FE4 D
JUN 10 2019
Components
LocationOwner's
Name
Map/Parcel#
Q
Address
Lot#
Telephone#
Installer's Name
, ,a.
Designer's Name �✓
Address PO J3 GA
,� I
Address
Telephone# )
y
Telephone#
$•n�;." ype of Building� A Si M!4 Cn �s'/ Lot Size
welling -No.of Bedrooms
Other -Type of Building No. of persons
Outer Fixtures
Design Plow (min. required) gpd Circulated design flow
Plan: Date Number of sheers
Title
Description of Soil(s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS
Name: of Soil Evaluator
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
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 system in operation until a Certificate of Co pli nce, has been issued by the Board of Health.
Signed es Date, C
e �
{ ��,,ys� Iry 5 � � �� �.�,E F.✓ F� y r „�frJ��`"�' � nr'�,
No P.,°%3m',.�;,r'-/s/ CCL ^a r, j
/ COMMONWEALTH OF MASSACHUSETTS �
Board q l-leallh, AQMQ18;"('-( ,Mil. 0,71
CERTIFICNI'E OF COMPLiANCF
Description of Work: E ftndividual Component(s) ❑ Complete System ,✓,,;,,,,l ,f .r' r/s
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.j, Upgraded ( ), Abandoned ( )
at 1 l 17,
has been Pinstalled to accordance with the proyisious of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. /°" f/r '!�,'dated f`i',42 Approved Design Flow - (gpd)
'a + °1 .�. f'rS
Installer F'`3 9" ;
Designer: Inspector x") (.,-"�-j % Date:
The issuance of this permit shall -not be construed-asm,goarmtee dint the system will'function as designed.
COMMONWEALTH ALTH OF MASSACHUSETTS
Board of Health, 1vi'-mt)&,lW -1 ,MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Rep i '( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at s, 11 as $ . «� as described in the application for
.m- " " . -,
Disposal System Construction Permit No. - /11/ ../-1 ,dated ^ ✓`
Provided: Construction shall be completed within three years of the date of this permit All local conditions must be met.
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Form 1255 Rev, 5196 A.M. Sulkin Co. Wagon, MA DatE' � /� ,��Board of Health