HomeMy WebLinkAboutApp-Permit-Compliance20 COMMONWEALTH OF MASSACHUSETTS RECEIVED
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V f�"/� Borctrl ofHaalth, ������ . MA, C� ���
APPLICATION FOR DIS' OSAL SYSTEM CONSTRUCTION L ATH DEPT.
Application for a Permit to Consn uctO Repair Upgrade ( ) Abandon( - ❑ Complete System Individual Components
Location s'
Owner's Name
Map/Parcel# �� —
Lot#
Address I
Telephone#
histaller's Name CQ
�f rL. -(�(1S
Designer's Name
Address .,(�- 'y6
CC,�-�U�
G. �(-(� QzG, i�
Address
Telephone# S'G� Za/0 ZSR
77 '? Z2 Z2 �/
Telephone#
Type of Building
Dwelling - No. of Bedrooms _
Other - Type of Building _
Other Fixtures
Design Flow (min. required) _
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of shells
OF REPAIRS OR ALTERAT7I-O�NS
o •i9_/.,_dc ,N�,c, t� aF
Name of Soil Evaluator
&,U Lot Size
No. of persons
sq. ft.
_ Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
D
The undersi s to Inst a ab esc ' u. Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es t ,toCF� e s operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
GkY Date 3 Z� z<mo
Inspections r
COMMONWEALTH OF MASSACUUSETTS
�.)fl Board of Health,Wrzm t)C9 @ti hLl.
..„
CPRTIFICATLSOF C6MPLIANCL ti r1",I' d~';� t �.i,,%� f, i
Description of Work: O"individual Component(s) ❑ Complete System,+s
The undersigned hereby certifythat the Sewage Disposal System; Constructed ( ), Repaired ((r)6pgraded O, Abandoned ( )
by:
at,a dry <
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 '2, 0 (r� l% dated .1 Approved Design Flow (gpd)
Installer
Date
Designer: �'� Inspector .� r 6
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
s
a
No.''k"'i(�tr��1.': (a
n? r y1!L_`
emission is hereby grante
COMMON -- OL MASSACHUSETTS
Board of Health, 111.4 6 IM4 , MA.
FEE r:, �>C-1
cv-m;'ewVAVh_I
DISPOSAL SYSTEM CONSTRUCTION PERMIT
r
to; Construct( ) Repair(af) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. r r •t dated ('' t-•
d
Provided: Construction shall be completed within three ? years of the date of this,pet mit All local conditions must be met.
P at Ill.
Form 1255 Rev, 5196 A.M. SAM Co. Charl0 m,MA Date h t 0-,'d$oard of Health s