HomeMy WebLinkAboutApp-Permit-ComplianceNo. E ON -10 C -1(o —14 (O l q //� /� �. ✓ / / FEE 675 P
t� 1' - , � ��
9g COMMONWEALTH LTH OF MASSACHUS�
Board of Health, LIA72MoUT-0 , MA.
APPLICATION FOR DISPOSAL —SYSTEM CONSTRUCTION PERMIT
lication fora Permit to Construct( ) Repair(tl4upgradeAbandon O - ❑ Complete System 43lndividual Components
Wocation 7-1 Owner's Name
.7q 1,"
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building
nth, -r FivnirP4
Design Flow (min. required) gpd Calculated design flow
Plan: Date 6 Number of sheets T
Title _—
Description of Soil (s) _
Soil Evaluator Form No.
of Soil
Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers ('), Cafeteria
Design flow provided Z— gpd
Revision Date
Date of Evaluation 41` % " /D
DESCRIPTION OF REPAIRS OR ALTERATIONS .L !' e / /
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 Compliance has been issued by the Board of Health.
Signed 099 n- ' Date r., -?, /Z
r 19
11
COMMONWEALTH OF MASSACHUSETTS o
0-11
Board of Health, A,=0t 04 MA. /
CERTIFICATE -Of COMPLIANCE
Description of Work; [dndividual Component(s) ❑ Complete System
The undersigned hereby certify rjhat,the Sewage Disposal System; constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by. % l
at
has been installe i if/ac d c
application No.
Installer
Designer: Sule-f�Z t e-�'
f
The issuance of thispermit shall
e
U
Ath7 tKe p N's'Xs of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated "-J! Approved Design Flow d)
f
Inspector: f +' Date: ar
no construed as a guar
rl'tee that the system will function as designed.
rJta FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, V 69M) i1'i7i , MA
.r
DISPOSAL SYSTEM CONSTRUCTION PERMIT/
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at / , v �� as described in the applic tion for
°Disposal System Construction Permit No. Ib'— > dated
-/ �/� f`t
Provided: Construction shall be completed w>thina�r e date of this petro.' local condi ' must be met.
Form 1255 Rev; 5196 A.M. Sulkin Co. Chadestown, MA Date Board otl <,
Map/Parcel#
��
f2[
Address
Lot# z A
Telephone#
Installer's Name
/`,!
Of t
Designer's Name
Address L"
f �
rpe/1 C `
Address -,74-7
Telephone#
V ., V
Telephone# 5-0 96) a
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building
nth, -r FivnirP4
Design Flow (min. required) gpd Calculated design flow
Plan: Date 6 Number of sheets T
Title _—
Description of Soil (s) _
Soil Evaluator Form No.
of Soil
Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers ('), Cafeteria
Design flow provided Z— gpd
Revision Date
Date of Evaluation 41` % " /D
DESCRIPTION OF REPAIRS OR ALTERATIONS .L !' e / /
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 Compliance has been issued by the Board of Health.
Signed 099 n- ' Date r., -?, /Z
r 19
11
COMMONWEALTH OF MASSACHUSETTS o
0-11
Board of Health, A,=0t 04 MA. /
CERTIFICATE -Of COMPLIANCE
Description of Work; [dndividual Component(s) ❑ Complete System
The undersigned hereby certify rjhat,the Sewage Disposal System; constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by. % l
at
has been installe i if/ac d c
application No.
Installer
Designer: Sule-f�Z t e-�'
f
The issuance of thispermit shall
e
U
Ath7 tKe p N's'Xs of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated "-J! Approved Design Flow d)
f
Inspector: f +' Date: ar
no construed as a guar
rl'tee that the system will function as designed.
rJta FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, V 69M) i1'i7i , MA
.r
DISPOSAL SYSTEM CONSTRUCTION PERMIT/
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at / , v �� as described in the applic tion for
°Disposal System Construction Permit No. Ib'— > dated
-/ �/� f`t
Provided: Construction shall be completed w>thina�r e date of this petro.' local condi ' must be met.
Form 1255 Rev; 5196 A.M. Sulkin Co. Chadestown, MA Date Board otl <,