HomeMy WebLinkAboutApp-Permit-ComplianceNo. 3 FEE
COMMONWEALT14
/ Of MASSACHUSETTS
Board of Health, V"ft VT7+ , MA.
APPLICATION F®I, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Vupgrade( ) Abandon( ) - ❑ Complete System ULividual Components
Location d
Owner's Name
Map/Parcel# M {F}
' 3
Address S 6 AA
Lot#
l
Telephone#
Installer's Name
i y
Designer's Name
Address� 9 /
Address
Telephone# 41
(> Q
Telephone#
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
+1
i
4r, e ,b j
Date of Evaluation
f 2<s�o
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 to pl the syste peration until a Certificate of Compliance has been issued by the Board of Health.
Signed 0��� Date �_ j�
Inspections
S �uL-71-- Se -e T—S- 4---' Vv
Na. _ _ .. ... FEE
COMMONWEALTH Of MASSA : TS
Board of Health, YARM O U 74 , MA.
CERTIFICATE Of COMPLIANCE a
Description of Work: 34ndividual Component(s) 0 Complete System
The undersigned hereby certify the Sewage Disp
J / ; sal System; Const acted ( ), Repaired (4 Upgraded ( ), Abandoned ( )
by: ! vs ltd'
cam^
g,
at !� a 1CX
has been installed in accorgance with the pro 'siorls of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. -1 w 3 dated /� l f Approved Design Flow (gpd)
Installer B'f'
t� Z'_- lx7j C,
Designer: """""" "'° Inspector: Date:
i r
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
_. OLIC _ ._C._�,_.e..�ivt. _JII. C_, ,:•O", c.0 .-�01•n ..
No.
COMMONWEALTH OF MASSACHUS r
Board of Health, YA-ll.&-o J%i4' , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT C/+
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at �� �' oma'P`� a as described in the application for
Disposal System Construction Permit No. dated 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. Chadeslown, MA Date Board of Health �
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