HomeMy WebLinkAboutApp-Permit-ComplianceNo. �P �c lq 338a-- ��/G% U FEE
CO MON �� 11 OF MASSACHUSETTS X1860
Board of Health, MA
APPLICATION PLICATION FOIA DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairtL/ Upgrade( ) Abandon( ) - ❑ Complete System OlinLdual Components
Location '3
Qu S . )O,f h 00
Owner's Name r' S
Map/Parcel# O S
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Address yw CM
Lot#
Telephone#
Installer's Name
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Designer's Name
Address `�
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Address
Telephone# ti
(5(j Met
Telephone#
Type .of Building - Lot 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 Design flow provided gpd
Plan: Date Number of sheets _ Revision Date
Title
Description of Soil(s).,
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS \ UccD NG u 4ZX C sAy-\ 1 I U r k �� V
The undersigned agrees to install the above des ed Individual Sewage;Disposal System:in accordance with the provisions. of TITLE 5 and
further agrees not to place the operation until a Certificate of Compliance has been issued by the Board of Health.
Signed. Date
&.1111 IC
Inspections
No. ! �' i� % - i9 "3-3,8 Z- FEF. _ G
COMMONWEALTH OF MASSACHUSETTS
77
Board of Health; , MA.
CERTIFICATE OF CO'IPI.IA?\
Description of Work: t dividual Components) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ,,),/Upgraded ( ), Abandoned ( ).
by SC - _
at
has been installce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /% dated . Approved Design Flow '""'_ (gpd)
Installer
Designer: ---- InspectorAt"
/ f Date:
The issuance of this permit shall not be construed as a guarat the system will function as designed.
_, . -. _
No. C.OTI riot t,)Y--FEE i. 0Q.
0 COMMONWEALTH OF MASSACHUSETTS
Board of Health, V" 16 UT j , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;; Construct( ) Repair( Upgrade( ) Abandon( ) an individualsewage disposal system
at_ U -C. V as described in the application for
Disposal System Construction Permit No. fi% ; dated Z, -11 --
Provided: Construction shall be completed within rs of the date of this perm`t. All local co.nA dons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date V / r Board of Health �� /�
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