HomeMy WebLinkAboutApp-Permit-ComplianceQa c 9-0�tP�S DGo-f o� �Y a
No. I'VE
COMMONWEALTH OF MASSAC14USETTS CW 142-,
hoard rfFlealth, Y6)-QV1Or r1+ , MA.
APPLICATION FOIJQ SPOSAL SYSTEM CONSTRUCTION PERM, IT
Application for a Permit to ConstructO Repair Upgrade( ) Abandon( - ❑Complete System Individual Components
Location
t/'(JS PG
Owner's Name
Map/Parcel#
0,3 0. O
Address d
Lot#
Telephone# ✓� G
Installer's Name
Desighcr's Name 2
Address 1%
.).lorXSids. 0✓;✓2t 5. Geda;5 14A
Address
Telephone#
I Telephone#
Type of Building
Dwelling - No. of Bedrooms,
Other -Type of Building
Other FIKLures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No
_ gpd Calculated design Row
Number of sheets
DESCRIPTION OF REPAI16 OR ALTERATIONS
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t lace t tem ' eraf until a rtificate of Compli.arrc has been issued by the Board of Health.
Signed Date /&
Inspections
No > L) 0 .. lM, ..._t✓` f ( " I )"�.� FCL
Eta a C�D�'INIDNW� ALTA OF MASSACHUSETTS EE
(U keg- C' cj '�yi Board of Health, Y- $1, 11 MA.
CERTIFICATE OF COMPLIANCE
Description of Work: /0 Individual Component(s) ❑ Complete System f•"'
t`
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired, , Upgraded ( ), Abandoned ( )
by:
at U- F f= 41'' )C
has been installed in accordance with the provisions
application No ' -•..2 1?`J ,dated
Installer -- ) . 7 .. ,✓ A -i %"i ,. V i 1--'.''.=i ;
310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
Approved Design Flow .. (gpd)
Designer: Inspector: Date:
Tile issuance of this Permit shall not be construed as a guarantee that the system will function as designed.
No t"' .".d C)....o4i €7(� �it: t`-�::.a{')%..r'6'��...._... .. _rCF ,
®t�[MI® ALTa11 OF MASSACITUSFTTS ' } C ' C p f
Board of Health, Y. g�IV160:0* MA. C" :``)P
DISPOSAL SYSTEM CONSTRUCTION PERMIT
r
Permission is hereby granted to; Construct( ) Repair"-)-) Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. S;0 , dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkln Co. CWOSIown, MA Date "1t'.^ ' �`>t8'`' Board of Health',.'
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