HomeMy WebLinkAboutApp-Permit-ComplianceNo. WDC-K.�o Ic" FEE � ` 0 0 � C
.16 , COMMONWEALTH Of MASSACHUSETTS ''7A /,,
Board oleg f Health, �JARMQO-n+ MA.
L
vl� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
pp ication fora Permit to Construct( Repair( UpgradeJ,<AbandonO-'ercImplete System D Individual Components
L cation
Owner's
ap/Parcel#
��
Address
t#
Telephone# ,z� ,✓l
i
Installer's Name.
Designer's Name"
Address..
%, 9
AddressQ
Telephone#
%_ r
Telephone# �. "- -_
Type of Building
Dwelling - No. of Bedrooms
Other Type of Building _
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 35 gpd Calculated design flow Design flow provided !%� gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
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 a s to not to place the system in operation a Certificate of Compliance has been issued by the Board of Health.
Sighed Date
Inspections
16- �
COMMONWEALTH OF MASSACHUSETTS
U � � 1�-1a,o
Board of Health, 9I�(LM(���_, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 4dtomplete System UK—-or�$rNGr P <T B tAP-14-00521
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded-�bandoned O 23✓1
by:,�-�
at �,Z
has been install
application No.
Installer �=
Designer:
The issuance of
M,6n-,/Rth"Th'e'frksions oplO CMR 15.00 (Title 5T and the . proved design plans/as-built plans relating to
dated -5-21 = f . Approved Design Flow�3 ! (gpd)
,,r,.-,�T_i , , Inspector: r -1 , Date: f
permit shall not be construed as a guaranteKthat the system will function as designed.
16-30 COMMONS 1.111 OF MASSAC1 USETTS
Board of Health., AgMOTM MA..
y, DISPOSAL SliSTEM CONSTRUCTION PERMIT
FEE 00
944
4 `4
Permission is hereby granted to; Construct( ) Repair( ) Upgrade L,) -Abandon ( ) an individual sewage disposal system
at -�� '� as described in Che application for
Disposal System Construction Permit No. (/0/- dated
Provided: Construction shall be comP leted� within o the date of this perm . All 16ca1 conn 'tions must be met. .►
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date -� �� Board of Health v