HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,Bmpc- 16" O 11 (0 o v(j (g q E) FEE OD
'a /6 Uj COMMONWEALTH LTH OF MASSACHUSETTS d4=0510
Board of Health, i�-I �0 (I 114 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
plication for a Permit to Construct( Repair( Upgrade(Xj Abandon( - HCl Complete System WA' t9t\NtO
❑ Individual Components
ocation
O _
Owner's Name � t
Map/Parcel#
Q Z 5
Address
Lot#
Telephone#
Installer's Name C-iT7M
ENTER9iZ6E,5INC.
Designer's Name
Address 2 b Eos (QrE
1-1 bLfWOY- wAy' +ifi eW01
Address q3j pT.(RA _ T
Telephone# 'job - 34 q - --300 1
Telephone# 5C6 _ 3 & 2
Type of Building K r -
Dwelling - No. of Bedroom
Other - Type of Building _
51D�J-r%AI-
s 'T Vj ID C Z
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures 14
Design Flow (min. required) 7- Z j O gpd Calculated design flow � 2) Design flow provided gpd
Plan: Date (Y 3 ') (Q Number of sheets (5 NS C- Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
a
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a s to not{to ace the V=tion until a Certificate of Compliance has been issued by the Board of Health.
Signed _ Date 0 ' 10,10 .
&SEK!COMMONWEALTHOF NIASS C� 49 57 0
Board of Health, Vii P -M 0 Q774 , ALA.
,. CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,( -Y Abandoned ( )
by:
at
has been installed in accordance with thep�rovision of 3 CMR 15.00 (Title 5) and the roved design plans/as-built plans relating to
application No. 46 -- --) +C# , dated 5 - � ��'Approved Design Flow (gpd)
Installer C,.k3 N3 L F'•--: L, 0
Designer: Inspector: , Date:
The issuance of this permit shall not be construed as a gua tee that the system will function as designed.
No. (} (4 ( i e Z• 7 -Ey pfZ1 S ¢S FEE $ `a 3 . LSC}
COMMONWEALTH Of MASSACHUSETTS c k 8510
Board of Health, P -MO V' MA•
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT I
Permission is hereby granted to; Construct( ) Repair( ) Upgrade 11P
Abandon( ) an individual sewage disposal system
at 1+31- PC) wo as described in the application for
Disposal System Construction Permit No. jrj r dated ` r
Provided: Construction shall be completed within,44t4� of he date of this permit., -,4, I local condition} must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 9 A/` -1C Board of Health ( �