HomeMy WebLinkAboutApp-Permit-Complianceti ..,.."No -- 11144 FACU T E 228 FEE
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/ Board of Health, A S Os , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon() - ❑ Complete System Individual Components
Location
Owner's Name D -AU) Bv2NeS
Map/Parcel#
�t/UC ?� (� C� 3
Address g CA a n i� eo c 2 w( A
Lot#
Telephone#
Installer's Name
C A �v�S A �at CA JAk.�n ijC.
Designer's Name 5, , r e -
Address
a S p9�J2
Address
Telephone#
(_ 39
Telephone#
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIP`TION OF REPAIRS OR ALTERATIONS
gpd
The unders' ede ?eeyto
all the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a t e system in o "tion until a Certificate of Compliance has been issued by the Board of Health.
Signed Date _ it
- `3 ' g 7
Inspections
No.J - C®MMONWFAIT14 Of MASSACHUSETTS FEE 1Vo AP
Board of Health, \j A e_en oo MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ! Individual Component(s) ❑ Complete System
The und�signed hereby certify that the Sewage Disposal System; Constructed (,� Repaired ( ), Upgraded ( ), Abandoned ( )
by: A Q._\ h (2A U o4q,'
at `ice C l-) }14- 1:� er, , �-../.-- Vr= N <.
has been installed in accord e with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No, 7 dated �V Approved Design Flow "-- (gpd)
Installer ( 4, 2/ C . �"Lz7(-10 Z X e -I a*Ao Q
Designer: ✓"`e- Inspector: 2! `I 9 !I' Date:
The issuance of this permit shall not be construed as a guarantee that tde system will function as designed.