HomeMy WebLinkAboutApp-Permit-ComplianceNo. C— [01-5v (a zz v AAA?w FEE
P /!� COMMONWEALTH OF MASSACHUSETTS &;V45-7 I�
Board of Health, Y b , MA.
APPLICATION.FOR MSP SSI. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ❑' Complete <System 0 dividual Components
Location C.Cr iJ
C)\.^+ I_6A
Owner's Namexr_0C_irqq%dof v
Map/Parcel# a
Address y� e/1yJ l Gv-.l Gt1in—i( Gc
Lot#
Telephone#
Installer's Name
Desgner'slVame
Address
Address
Telephone#
519 5
Telephone#
Type of Building I VltYN 1_� _ _ _ Lot Size sq. ft.
Dwelling - No. of Bedrooms /li 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.
OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Film
J I ,
Date of Evaluation
The.undersigned,agrees to install�,ht a above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and;
further agrees to not to plgce the system in operation until a Certificate of C pliaqce has been issued by the Board of Health.
Signed _ Date
Inspections
E
No.'60 A D -1 `f - �2�f (o � FEE
COMMONWEALTH OF MASSACHITSETTS
Board o f Health, MA.
CERTIFICATE Of COMPLIANCE
Descriptionof Work: .®individual Component(s) ❑ Complete System Z/
The undersigned hereby cert that the Sewage Disposal System; Constructed ( ), Repaired U raded ( ), Abaond
g C .' g P Y P �Pg
at �L � eo fz_C. 717N % 1l_z�'t
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. %' % dated �l Approved Design Flow ' (gpd)
Installer _
Designer: Inspector: Date:
The issuance of this,permit shall not be construed as a guar tee that the system will function as designed.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YAW 11( , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
C 15-'93
Permission is hereby granted to;; Construct( ) Repair \ Upgrade( ) Abandon( ) an individual; sewage disposal system
at. 4?�c 2 t f 4th i ;•� j �� . as described in the application for
Disposal System Construction Permit No./f, dated_
Provided: Construction shall be completed within three years of the date of this pe it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chade*wn, MA Date Board of Health Ci
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