HomeMy WebLinkAboutApp-Permit-ComplianceNo.&V& Ifo FEE - % / I
COMMONWEALTH OF MASSACHUSETTS
01,
Board of Health, 1 Ai2M " , MA.
f � APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct O Repair( /Upgrade O Abandon O ❑ Complete System O'Individual Components
Location a 7
Owner's Name
Map/Parcel# ::57,F .--
Address R
Lot#
Telephone#
Installer's Name
Designer's Nam
�.
Address 5 /ov
Address A;45/
en-,
Telephone# -565,— ��,� ��'
Telephone# -5L
sr— 0 —.9r 2 7
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms � Garbage grinder ( )
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required)gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS %tdvt�
The undersigned agr s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree n to piac th tem in operation until a Certificate7omp�ce has been issued by the Board of Health.
Signed + Dater tet" _
Inspections
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1'�il' 17.E In a*W
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1. FEE,
COMMONWEALTH OF MASSACflUSET
Board of Health, , MA
r
CERTIFICATE OF COMPLIANCE
Description of Work: Yd'Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (!Repaired (w) -,Upgraded ( Abandoned ( )
by: 0 s 4j,4C- 6.jS T!L L C
at o % / 4,f,,2/ /?S' Z 44 -2,—
has
,
has been install& in'�
application No.
Installer / o.;F/C//1
gitn T'9provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated 9` `%� '�/�. Approved Design Flow ::3 � gpd)
Designer: 4t,44 -'l 4;� Inspector:
Date:' "l /
The issuance of this permit shall not be construed as a guaran.We that the system will function as designed.
No. 16 —7K' Lt%����f 11 //lJ�� FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, \(A O k n* MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is jjherebygranted to;; Construct( ) Repair (&,-y Upgrade( Abandon( ) an individual sewage disposal system
L
at t� 7 14.ee, in 7 L A'/7.4 - as described in the application for
Disposal System Construction Permit No. 4 dated, .
Provided: Construction shall be comp_.,leted within .wd-; ...® of the date of this periA)t. All local conditions must be met.
� ;
/Form 1,2555 Rev, 5//96 A.M.Sulkin Co. CChha`destown, MA Date -1 i —7 Board of Health