HomeMy WebLinkAboutApp-Permit-Compliancea 1 �f �%J/FEES
COMMONWEALTH LTH ®F MASSACHUSETTS CHUSETTS 0
Board of Health, VO4W—�
APPLICATI®N FOR DIS ®SAL SYSTEM[ CONSTRUCTIO=Components IT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - ❑ Complete System
Location 2 w t a
Owner's Name�/c
O -eo-e
Map/Parcel# 7
Address erc
-X-eA l ro (00
Lot#
Telephone#
Installer's Name C S p l�
G` ���
Designer's Name
Address P.C.
Address
Telephone# 50$ ' IJ 7l-L'Z
-Z 201 g
Telephone#
Type of Building ( -e 5'
Dwelling - No. of Bedrooms _
Other - Type of Building
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
Lot Size
No. of persons
sq. ft.
_ Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCFJPTION OF REPAIRS OR ALTERATIONS -e JL-'wl Lec,1C 4M k
Ci J, c �e ao -bre -nr �
-"?/
The un.
further
Signed
Inspections
to ' tall the s ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
p th ration until a Certificate of Comlianehas been issued by the Board of Health.
Date 9-13-9
r //,;"> 9 COMM ON�LT14 Of M ASSAC14USETTS o ����__ ?-,-7 7 7
Board of Health, SYN 0 � , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Lidual Component(s) ❑ Complete System
The undersigned hereby ce tify that the Sewage Disposal System; Constructed O Repaired Upgr ed ( ), Abandoned ( )
r
by: CC < < �j OQ� C (CA .E 4 ,C -W`J ?e (0(1
at Z Am-&oFAK,-
has been installed in ac(
application No.�
Installer
1 �,CC,Po
ice with the 'provisi(ns of 3P CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated G� "7 l{? Approved Design Flow (gpd)
Designer: Inspector: f L.,V Date: U —1Z 7
The issuance of this permit shall not be construed as a guar tee tldt the system will function as designed.
(`C. (,! iC��ir:,,i,/CrC"'f-��i:C.CfJ '��0.>-i
No. 11+� � p� CAPE cci)scY-'tic (Aj5p' FEE
COMMONWEALTH OF MASSACHUSETTS C,h_ -� 2-7 7
Permission is hereby gran
at
Board of Health, Vdl2oburm , MA.
DISPOSAL SYSTLM NSTRUCTI®N PERMIT
to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. dated
-r
Provided; Construction shall be completed within tpree.Vears of the date of this permit. All local conditiopsmust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date %�oard of Health ' �`