HomeMy WebLinkAboutApp-Permit-ComplianceNo. j3ai+DC- ( t "3SY `I !'(,(,fj�ji� n ,�6 S � FEE U 5 00
COMMONWEALTH OF MASSACHUSETTS
�2Co�P
Board if Health, Y&AW011 14- MA.
C' APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
1.
(,• Ap lication for a Permit to Construct( ) Repairm Upgrade( ) Abandon( - ❑ Complete System J.)Ibidividual Components
f:
Type of Building
Dwelling -No. of Bedrooms
Other -Type of Building
Other FiXLUre5
Design Flow (rain. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
_gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRSORAITERATIONS t t/IiVV E-"NOVC– 'l' \Uv- tC Lu �
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 plat the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ��,� Date (a /191 !(6(
No. �nC � ""�`".t "°' 1 `66-t. '"7/ •• r ro P. ° 'FE13 00,
t
COMMONWEALTH
O MASSA_.. _TT'S
i Board o% Health, 7✓A L_Lo 1)"r4 , MA.
a �
CERTIFICATE OF COMPLIANCE
Description of Work: )[hdividual Component(s) ❑ Complete System "�°' e ,lt ,� •r(�,-. ' .� ,..,�/'`` " ""^ "`�'----^
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded O Abandoned ( )
has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. t /✓'-r•`'%`r dated ^:r' , % /" 2. Approved Design Flow - (gpd)
Installer ° In , (. r,
Designer: a-^"° bnspecto•: _
The issuance of this permit shall not be construed as a guaral
No. . a (" �) "`..`a."C (,� i„ TI(E) IT, 1. 0 fQ j") "0 C71 n$\J
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( #6) Upgrade( at c� i C,�Ee" f? t) `'.t -. OW(—'•71 ---
FEE %•,pf 5�,�.� G�//(,1 (
) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No ,(? /1"1 f� , dated
Provided: Construction shall be completed within three vd lrs"bl the date of this permit. All local conditions nmst be met.
/r"
Form 1255 flee. 5196 A.M. SulBln Co. ctormlnn, Mn; Date f4t .<^1 - I 7 Board of Health. "^'. r, /m r`i�✓' C t` N'.
io)
(prv�6pe_ (n
Owncr's Namc `J1n PaY196ur
aIocation
ap/Parcel#
Address G( 6- irbo - n
Lot#
Telcphone# -7
Installer's Name
�( �� '�
Designer's Name
Address Po (�?a S. .i
Address
Telephonetk
(
Telephone#
Type of Building
Dwelling -No. of Bedrooms
Other -Type of Building
Other FiXLUre5
Design Flow (rain. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
_gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRSORAITERATIONS t t/IiVV E-"NOVC– 'l' \Uv- tC Lu �
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 plat the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ��,� Date (a /191 !(6(
No. �nC � ""�`".t "°' 1 `66-t. '"7/ •• r ro P. ° 'FE13 00,
t
COMMONWEALTH
O MASSA_.. _TT'S
i Board o% Health, 7✓A L_Lo 1)"r4 , MA.
a �
CERTIFICATE OF COMPLIANCE
Description of Work: )[hdividual Component(s) ❑ Complete System "�°' e ,lt ,� •r(�,-. ' .� ,..,�/'`` " ""^ "`�'----^
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded O Abandoned ( )
has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. t /✓'-r•`'%`r dated ^:r' , % /" 2. Approved Design Flow - (gpd)
Installer ° In , (. r,
Designer: a-^"° bnspecto•: _
The issuance of this permit shall not be construed as a guaral
No. . a (" �) "`..`a."C (,� i„ TI(E) IT, 1. 0 fQ j") "0 C71 n$\J
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( #6) Upgrade( at c� i C,�Ee" f? t) `'.t -. OW(—'•71 ---
FEE %•,pf 5�,�.� G�//(,1 (
) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No ,(? /1"1 f� , dated
Provided: Construction shall be completed within three vd lrs"bl the date of this permit. All local conditions nmst be met.
/r"
Form 1255 flee. 5196 A.M. SulBln Co. ctormlnn, Mn; Date f4t .<^1 - I 7 Board of Health. "^'. r, /m r`i�✓' C t` N'.