HomeMy WebLinkAboutApp-Permit-ComplianceNo. i tll." 6 �f � r (�, �X/l NIU_V �[✓ u Q �� EE b�i.��
COMMONWEALTH OF MASS C14USETTS c�'►�rS�Z
f Board of Health, �YARM n t M MA.
AP ICATI®N FOR DISPOSAL SYSTEM CONSTRUCTION� %?
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon - ❑ Complete System ❑
Location A
Owner's Name
Map/Parcel# a `
Address %.;t,
Lot#
Telephone# _f
Installer's Name
Designer's Name 16 M41 -vi 44"L silw"
Addressf—
Address
Telephone#
Telephone# J` 6167-3
Type of Building Lot Size sq. ft.
Dwelling - No. of BedroomsGarbage grinder ( }
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) T� gpd Calculated design flow Design flow provided f!! gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) .el —c �b i4
Soil Evaluator Form No. t/ Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS���a L/1�iC i
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further azcus to not to place the system in operatio ntil a Certificate of Compliance
®has been issued by the Board of Health.
Signed Date
a
+� Inspections
, No. _!v R D c- t L'9 f 4
e t Pl�xI4" 70q-0
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �i%AIZ NO t 1 -DA
CERTIFICATE Of COMPLIANCE
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Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned O t'
by: r.f
a -1
.l
has been installed tin' c an ith t ? e provisions of 310 CMR 15.00 (Title 5) and
thea proved design plans/as-built plans relating to
application No. t dated '`� ` Approved Design Flows—(gpd) '
Installer /V
Designer: h �a4 YT r� Inspector: Date: .r� ;4-&
The issuance of this permit shall not be construed as a guarVt4e that the system will function as designed.
- No. Pr7cT !,)c� FEE .f 00
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COMMONWEALTH Of MASSACHUSETTS
Board (f Health, �& W X11" (4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
t Ir
at 1.4 _ ,n eA ¢ "-s" � � as described in the application for
Disposal System Construction Permit No. y_ dated
1610 /6� • 7
Provided: Construction shall be completed within �o>f�the
, date of this permit All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadestown, MA Date !! BoaT'd d HeJ!h , n
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