HomeMy WebLinkAboutApp-Permit-ComplianceNo.C) 4-X- [( -10 OV7
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COMMONWEALT14 Of MASSACHUSETTS
and of Health, p� t"101Tf + , AIA. MIT
r P/ ICA ION �® DISPOSAL SYSTEM[ CONSTRUCTION PEP
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
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Location
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Owner's Name
Map/Parcel#
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Address Qe, h?, ,)N
Lot#
Telephone# [
Installer's Name
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Designer's Name ff
Address
Address )12,W dA6
Telephone#
Telephone# a _ , —97C%-,
Type of Building I Lot Size sq. ft.
Dwelling - No. of Bedrooms 3tf 4.0,/' Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 411 10 gpd Calculated design flow__ Design flow provided_ gpd
Plan: Date Number of sheets _ Revision Date
Title
Description of Soil(s) , k -
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 place the system in operation until a Certificate of Co plia ce has been issued by the Board of Health.
Signede� Date
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FEE
COMMONWEALT14®f MASSACHUSETT L
Board of Health, yA R M O t)"I-4 —MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) ❑ Complete System s
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
at
has been installed in accordance hctl�i provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /I 1 dated"') (L Approved Design Floww a (gpd)
Installer
Designer; / ,/ s4; ,+! Inspector. -r - ' ! Date: ✓
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. f
FEE
/( > 7 COMMONWEALTH Of MASSACHUSETTS
Board of Health, P V_M0l)-Tl'l' , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair,( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at �`� S `` `'�-- as described in the application for
Disposal System Construction Permit No. / t^ ) , dated
Provided: Construction shall be complete within thrze-=ars of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date /.h Board of Health