HomeMy WebLinkAboutApp-Permit-ComplianceNo. C-17 FEE -,O</—
COMMONWEALTH
�
Board of Health, /7 /e MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (LKpgrade( ) Abandon( ) - ❑ Complete System L17ndividual Components
Location 41.3-5- -5 V A M r
i7- W - YW
Owner's NameP,4 / c -/,q yt%/ ZT A,1,,4A-
Map/Parcel#
-
Address 7 3S' S qA M rpt s'?
Lot#
Telephone#
Installer's Name
Designer's Name
Address 03 ,41*'
37' W _ ! 6'
Address
Telephone# I g _ ��` -
pGo
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
M
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
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS F /► CC *1 4 J A.
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a s to not to place the system . peration until a Certificate of Compliance has been issued by the Board of Health.
Signed 0.4. Date's d
Inspections
No. 04
Description of Work:
The undersigned hei
by:
at
t
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, le
�//'' CERTIFICATE OF COMPLIANCE J�
Cl'Individual Component(s) ❑ Complete System
ry certify that the Sewage Disposal System; Constructed ( ), Repaired (4 1rpgraded ( ), Abandoned ( )
�C G 3So ,ZJ/�1x! 57- 4A. -
has been installed in accordance with the ovis ons of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application q, dated _Q Approved Design Flow. (gpd)
Installer
i
Designer: Inspector: c�-. ! �"`� Date:
r
--The issuance -of tkcis permit shall -not be construed -as a xarantee thattthe_system will � ction as designed.
No. �) / {� t''FEE �
COMMONWEALTH OF MASSAC14USETTS
f �i�r.>/ti% �l �'✓�
Board o Health, // /� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Permission is hereby granted to; Construct( ) Repair ( L)''Upgrade ( ) Abandon ( ) an individual sewage disposal system
at / 3 J S (1 iYi /yl F /P 57- Gt /- Y� /� as described in the application for
n
Disposal System Construction Permit No. 'A G, dated
Provided: Construction shall be completed within f the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date F _� 2� Board of Health