HomeMy WebLinkAboutApp-Permit-ComplianceNo. O�lDC—I(oJ gllTl'L-((--00ggIS— FEE ;0,0a
COMMONWEALTH OF MASSACHUSETTS c y53
71IC'A
'd of Health, Y. T I+ o , MA.
14
TION I� DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
�aZIINApplication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location f
Owner's Name
Map/Parcel#
Address
Lot#
Telephone# 61-7
Installer's Name ELCci KI
1 Designer's Name Ac ran n
Address ��
e {. Address Box
Telephone# 5 D� "� —
Telephone# Q _ ,ZR
Type of Building :�Wy
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. re ired) � gpd Calculated design flow Design flow provided gpd
Plan: Date O 1 o5 Number of sheets � Revision Date
Title
Description of Soils) _
Soil Evaluator Form No.
Name of Soil Evaluator
OF REPAIRS OR ALTERATIONS 1
. h r-iAA-,- r i qD'
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreee-0 �t/jo place the �teDmeration until a Certificate of Compliance has been issued by the Board of Health.
Signed ,t7[ 17?�K�G�iln Date G�
Inspections
cG�� FEE
f COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yagmn e 7m1 - , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 'Ll Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ); Repaired ( )> Upgraded ( )> Abandoned ( )
at 1
has been installed in rde wt��-d't�isio�'ir s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to,
application No. , ' dated . Approved Design Flow (gpd)
Installer 'L -1/j! lgp -T- = i
Designer: %� i t^ u^� ;` . - r Inspector: Date: 'c /
, �. ,
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
1 a l ll P 4- FEE 4- :o
No. Coca �l 4�_ ..°,�i ^� �J��} ...a V }� � (� l,�j� �.�_
COMMONWEALTH Of MASSACHUSETTS cjz * 3q� 3
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed withinaof thdate of this permit: All local conditions must be met.
+ F' I 1255 Rev. 5/96 A.M. Sulkin Co. Chadest_ownn,, MA / Date ! e Boar Of 1 I,e��alth
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