HomeMy WebLinkAboutApp-Permit-ComplianceNo. O �/16. DZY J 17— I!FEE `G V v
COMMONWEALM Of MASSACHUSETTS co 2Y�
Board o Health,ydfjw, MA. bve�l,
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION// PERMIT
A plication for a Permit to Construct( ) Repair44/Upgrade() Abandon() - ❑ Complete System kindividual Components
Location
Owner's Name/
/r K
Map/Parcel#
Address
r
Lot#
Telephone#
Installer's Name O f �°
Designer's Name
iy
Address L11 ,✓e ck -14 ✓r
i
lj Address
Telephone#
Telephone#
r,
7 00
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (mins. required) l3.�d gpd Calculated design flow
Plan: Date b `' ;� - �O Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No.
X"C
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation -e;` /y` /6
DESCRIPTION OF REPAIRS OR ALTERATIONS ��i �i -j-
The
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 Date 0— ZAK
A'
Inspections
s
No.t��-�Y7 U "i / Acs/ . / ' y/4EE s
COMMONWEALTH OF MASSACHUSETTS
Board of Health,1�V
CERTIFICATE Of COMPLIANCE
Description of Work: I'Individual Component(s) ❑ Complete System
The undersigned hereby certify thaj the Sewage Disposal Systee'' Constructed ( ), Repaired ( ), Upgraded (`T,,<bandoned ( )
at
has been installed in accgFdanjer. the provisi ns of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ;/��L'�' dated `1 Approved Design Flow gpd)
Installer 14-11J�4
Designee %_ (! , �� Inspector: .G-r'f ! C 1 �1+� Lam" Date: � 15,
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
--- No. t (1 t L PiCi" 7•--- em FEE — 66
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COMMONWEALT14 Of MASSACHUSETTS
Board of Health, Y&OMQOl f , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(V)' Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. dated "� �✓��.
as described in the application for
Provided: Construction shall be completed within AiF@e tmvof th(ate of this permit. All -local conditio must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date „ f C0 Board Health �
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