HomeMy WebLinkAboutApp-Permit-ComplianceNo. F -,�,,6e ` J/Ly "Z ' FEE 06-6--M
COMMONWEALT14 OF M ASSAC14USETTS
Board of Health, I691W l)"ilk , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair( Upgrade( ) Abandon() - ❑ Complete System Individual Components
Location CZe lzxf
Owner's Name C' C5/7 k C y
Map/Parcel# F-3
AddressIF
Lot#
Telephone#
Installer's Name
QL Designer's Name
Address
Address
Telephone# ?
Telephone#
Type of Building av5 571,A -C -lc E d Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS tRC pl4 C/ !64 12i�✓ l 1)1-4-e-, lD cnto p �dC
gpd
The undersignedagrees to ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t t to a thetem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date %v?f
Inspections
No. FEE
COMMONWEALT14 OF MASSACHUSETTS
16
Description of Work:
The undersigned het
by:
at Cf 4C
Board of Health, - � O U -Ln , MA.
CERTIFICATE OF COMPLIANCE
"I, vidual Component(s) ❑ Complete System
>y certify that the Sewage Disposal System; Constructed ( -Y,"kepaired ( ), Upgraded ( ), Abandoned ( )
G�19/�/- GcJrZ�
c
has been installed in accordance with the provisions 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
Designer: Inspector: Date: -7 7
The issuance of this permit shall not be construed as a guarritee'that the system will function as designed.
No. / / l w (1�1 i� % t V� FEE
COM MONWEALT14 OF MASSACHUSETTS � c �-
Board of Health, y14fLM0 Q -M , MA. /�/v
DISP®SAI. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(1,16pgrade ( ) Abandon ( ) an individual sewage disposal system
at f 6 % Q C C Ale- as described in the application for
Disposal System Construction Permit No. J, dat/e�d�7� c1 '
Provided: Construction shall be completed within tars o the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 7%L -e"Board of Health