HomeMy WebLinkAboutApp-Permit-Compliance6 tATR,�2o —b O7, _(v 3 5�
COMMONWEALTH OF MASSACHUSETTS
Nt,czlf, TO <i v'[ Board of Health, yFk(ZhIOU-W MA. NOV O d 019
/f 'AEPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTION �EI� ITr{ca,i ii D,_
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - 0 Complete System OIndividual Components
Location
Owner's NameLa-nNO
Map/Parcel#
Address
NIC IC
Lot#
Telephone#
Installer's Name �� �-� 1 �-
Designer's Name W
CA
Address j(jG °`7td;T11 04jaW Y`C).
Address -1
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Telephone# o!�Sq 2j2
Telephone# A28 30�
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.re7,qruired zl Jd gpd Calculated design flow
'l�
Plan: Date � Number of sheets
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow provided gpd
Revision Date
Date of Evaluation
The undersigned grees t >s a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees l/ace [em in operation until a Certificate of m jance been issued by the Board of Health.
Signed A Date —OF
Inspections �ro
No. FEE
L�
COMMONWEALT14 OF MASSACHUSETTS � a
Board of Health, /tai'; M0UT?-6 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,('), Abandoned( )
by
at
has been installed in accordance 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 ''. t ; (gpd)
Installer i,_. ,l 1—T ' I
Designer: -.X' , �0Inspector: .X. 4 t—o Date: II)
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No )w'(li' ) ;. __a -.�jC_, £'i14 )��a [h FEE
'
COMMONWEALTH OF MASSACHUSETTS
Board of Health, yAi hlol)J L , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) UpgradeO` Abandon( ) an individual sewage disposal system
at 2, 1 ,D ? -0 as described in the application for
Disposal System Construction Permit No. 7" <`, dated
X
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. Sulkin Co. ChakAnn, MA Date Board of Health 1
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