HomeMy WebLinkAboutApp-Permit-ComplianceNo. F30R-D C-16--619 q FEE DD
COMMONWEALTH Of MASS Y'1. 11tUSETTS
Board of Health, ��13 R 10 QT4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair(,� Upgrade( ) Abandon( ) - ❑ Complete Syste vidual Components
Location 0 jh d i' d Re
Owner's Name C A hQ- A h R.r Sb Y.
Map/Parcel# / Zs, r2y
Address Pd�hT e\ t�S
Lot#
Telephone#
Installer's Name J o�� Y �'t�
Designer's Name
Address 117 N6r SikQ,
Address
Telephone# �� - s - W I
Telephone#
Type of Building
Dwelling - No. of Bedrooms,
Other -Type of Building
Other Fixtures
Design Flow (mina required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
Lot Size
No. of persons
sq. ft.
_ Garbage grinder( )
Showers( ), Cafeteria ( )
gpd Calculated design flow Design flow provided
Number of sheets Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
av,cptkQ' +ee- W;Ah
gpd
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 0 a4� DateU Ay
Inspections `� s� �X t S T l - 1 C -e - C) b
No. �-EVV 1 ! FEE 00
/ C®�'l[� ONWEAlLT14 OFMASSACHUSETTS � , -
`12 �y1 c r�N MA. -712
Board ofHealtla, -
T ,
CERTIFICATE Of C , I��P�.Ii�I�CE��r�'F
r,
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal Sysiam; Constntctedl ( ),Repaired !' Xj, Upgraded ( ),Abandoned
'PO
by: Acc l-) SFCli�C.l�
1
at y -Bo t tia -r r� F 20 c r--
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. Ao' - ' O dated Approved Design Flow I (gpd)
Installer #�
Designer: - Inspector: M Date: , r
The issuance of this permit shall not be construed as a guarantee th4f-the system will function as designed.
No. 60++ of 7 A, C U FEE
COMMON OF MASSACHUSETTS r2-CZX- #-3-71
Board 6 Health, � ?�. —, MA.
�, DISPOSAL SYSTEATONSTRUCTION PERMIT V IL G r r
T
Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at k t� E tl t b C Z/ as described in the application for
Disposal System Construction Permit No. & 1 b , dated 9-/k-/ b.
Provided: Construction shall be completed within three years of the date of this er itt.�A(ll local conditions must be met.
Form 1255' Rev; 5/96 A.M. Sulkin Co. Chadestovn, MA Date �✓ , i � Board of Health � `