HomeMy WebLinkAboutApp-Permit-Compliance' No. fJ�� i/%1- d / tJ�� j `'� / �� � FEE
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COMMONWEALT OF MASSAC14USETTS u& l °5,
Board of Health, Try W t/- , MA.
-APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair�r Upgrade( ) Abandon( ) - ❑ Complete System Xindividual Components
Location ;ka3 -
Owner's Name
Map/Parcel#Address
lot
A0 . c—
Lot#
Telephone#
Installer's Name �5
Designer's Name 14 -
Address
Address ®
Address
Telephone# 509 -77
1 Telephone#
Type of BuildingLot Size sq. ft.
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 _
Plan: Date Number of sheets
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Design flow providedgpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS T S c?t.,ce, OC1.e-1 bZ t. T Z"& O$j Som'" Jp f c-,1'�L 0.1
fiA2 . -Z _ _ E -t' - Z) ~- 3rs>c i tJ 1714- &15�=P' - -. bd -.�—,PCZ
g e> V —go
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no to place the system in operation until a Certificate ofpCompliance has been issued by the Board of Health.
Signed Date
..Inspections.
No. 1."D s'1%l i� °t FEE, 4
COMMONWEALTH OF MASSACHUSETTS 0 _5
0
Board of Health, Y49&VU72t
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) D Complete System/
"! 6kA,
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (, Upgraded (3), Abandoned ( )
at JE!ft �r i '�
has been installed in
application No.
Installer
with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated, � z- /45� . Approved Design Flow "� (gpd)
Designer: %1�'r Inspector:. 5 Date: i, s I '
.-s
The issuance of this permit shall not be construed as a,guarantee that the system will function as designed.
No. .6o 3?c-19-0J-77 CAf CWCDE / F_ FEE �1
COMMONWEALTH Of MASSACHUSETTS I ��
Board of Health.,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to,; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at 1z TtYA) Pno as described in the application for
Disposal System Construction Permit No. ,r dated
Provided: Construction shall be completed within.tlr-ee years of the date of this peri & All local conditigns must be met.
Form 1255 Rev. 5196A.M. Sulkin Co. Chadeslown, MA Dat ^ _/"t Board of Health !r /c'. jJ ! i -1/