HomeMy WebLinkAboutApp-Permit-ComplianceNo. K0Wm-t9--0q5F?
FEE: (j
COMMONWEALTH Of MASSACHUSETTS (Lf3go �
Board of Health, 1 QX M t-?( kbC) MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( epair ) Upgrade( ) Abandon( ) ❑ Complete System 0 Individual Components
Location p2 %
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Owner`s Name S e h PK O e f5
Map/Parcel#
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Address
Lot#
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Telephone# 663, lPra 77
Installer's Name77
Designer's Name A-, C ,
Address'„a
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Address
Telephone# 7$,
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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 Soils)
Soil Evaluator Form No. Name, of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 toace the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
i
No. f30: ' �% l f FEE J
COMMONWEALTH 1LTH Of MASSAC14USETTS 1q3 9 01
Board of Health; YU46 1)714 MA.
CERTIFICATE Off' COMPLIANCE P �
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constricted ( �Repaire ( ),Upgraded( ) , Abandoned ( ).
at Ci 04, rj
has been installed in accordance with Elie twovisigns 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: r ."'" ."� Inspector: — A t,.2 le_ -A Date.:
The issuanc++e of this ;permit shall not be construed as a guarantee that the system. will function as designed.
No. 1 �I'"' 4 p s� 1FEE'
r X7'--1 1� C-1 COMMONWEALTH ®I~MASSACHUSETTS �
Board of Health,%ZMbl� , MA. ) ( 6\
DISPOSAL SYSTEM[ CONSTRUCTION;1PER IT 6
Permission is hereby granted to; Construct( d-:) Upgrade.( ) Abandon( ) an individual sewage disposal system
at / y T as described in the application. for
Disposal System Construction Permit No.( _, dated a - ).A.—/ T
Provided: Construction shall be completed within three years of the: date of this permit. All local conditions must be met.
Form<1255 Rev. 5/96; A.M. Sulkin Co. Chadestown, anti Datee -17Board of Health � J