HomeMy WebLinkAboutApp-Permit-ComplianceNo. /� �® I,/>��7�c' /��� L/��/L FEE 5�0d
COMMONWEALTH LTH ®f MASSACHUSETTS /� `7�
Board of Health, YailJbloonl , MA.
APPLICATION F®I, DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location�Iq
Owner's Name «
Map/Parcel#
.r
A
Address
Lot# s
,
Telephone#
Installer's Name VVq5
bio_ .
Designer's Name
Address
19" t &_14 4
Address
Telephone#
6 400
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.
Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
gpd Calculated design flowCJ� Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n p ce the tem in o eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date _
IA- R t c -r o -C `fes — _
Inspections
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No. FEE
COMM O LTII ®f M ASSACIIUSETTS 7�
Board of Health, Yid P—M 0 Vrff , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigrAd hereby certiA t�at the Sewage Disposal System; Constructed ( ), Repaired WUpgraded ( ), Abandoned ( )
by: R M h / I&C
at '7 `f (U (es 6-fe-14 Fi C)
has been installed in accordan e with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
" /o , dated -� %` Approved Design Flow _J3e (gpd)
application No. /
Installer !%d
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function, as designed.
No. ` f - % U 6 7� ��^j " i� FEE _ i . (✓
COMMONWEALTH EALTH MASSACHUSETTS
Board of Health, YAP_/1'10 IJ , AIA.
DISPOSAL SYSTEMISTRUCTI®N PERMIT
Permission is hereby granted to; Construct(-) Repair( G Upgrade( ) Abandon( ) an individual sewage disposal system
r-- ff
at �Vl v le(- v'[en i 11)` as described in the application for
Disposal System Construction Permit No. % f, dated:
Provided: Construction shall be completed within f r f tiie date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date I / / Board of Health / �
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