HomeMy WebLinkAboutApp-Permit-ComplianceNo. V iTr D C (o '-DG 1 I �J LSJ•� lD Ct 6 �f' U �l '' f� - --�—
FEE ®�
COMMONWEALTH Of MASS C NETTS
Board of Health, l Vd 4 BTW , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (4 -'Abandon() Complete System ❑ Individual Components
Location ® S •
Type
Owner's Name fi
Map/Parcel# 0-7 8 JJ l
Address 10 3CaD1.
Lot#
Telephone# -20 72-9/)
Installer's Name 0+6 Q(COWATI OO t(Q G
Designer's Name R
Address 14 �Jouvi W �rLFS-�
Address �%G Q� (1 j t d rn
Telephone#
Telephone# '66K -
6K -
Type of Building I
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size C f sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mi .requid) 3 gpd Calculated design flow Design flow provided gpd
Plan: Date l 2�t 5s Number of sheets ' Revision Date
Title
Description of Soil(s) //
Soil Evaluator Form No. Name of Soil Evaluator onSi�WC. Date of Evaluation i Y
OF REPAIRS OR ALTERATIONS R I D 15M
Czl If in SD6 nrAj ra,nrnher
The undersigned ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees on t place theemAmration until a Certificate of Comp lia ce has been issued by the Board of Health.
Signed 0 A U Date
Inspections
y�,� '/
No. 604DC-1�o g (¶�(�T % /_ EE a` 00
/� 'l.®T'IMON �Y�Y LT14 Of SSA'l.]t�t�LJSETTS /)A'4e-1
Board of Health, VA" 0 IMA, MA.
CERTIFICATE OF COMPLIANCE oZ`
Description of Work: ❑ Individual Component(s) complete System
The undersigned her by certify thattheSewage Disposal System; Constructed ( ), Repaired ( )> Upgrades.(- Abandoned ( )
by: I- i ('l 1 tl l 16 n
at 1 C e f
has been installedif- ccor anc ith e;?pZo isions of 10 CMR 15.00 (Title 5) a d th a roved design plans/as-built plans relating to
applicatto� n 1V,b. %� dated 2 '" Approved Design Flow
Installer 0
Designer:I�f)1 i'1 I--, Inspector: �4 f' , f /�.M�l/.�i( Date: .-' /`'r
The issuance of this permit shall not be con •ued as a guarantee that the syste`tn will function as designed.
Nolo Rpc -1(p-(8 7-11 FEE 5 00
/� --,/ 7 COMMONWEALTH Of MASSACHUSETTS Ck'' 3470
Board of Health, yAg M 0 0144 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( )
at
( ) Upgrade.(.�bandon ( ) an individual sewage disposal system
as described in the application for
t
Disposal System Construction Permit No. /b/ -7*"'? , dated
~-/4!� --- F
Provided: Construction shall be com l d within4 P years f the date of this permit l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date - e4 14 Board of Health