HomeMy WebLinkAboutApp-Permit-Compliance6`
No. 60 " C_16 ^0v 4o
COMMONWEALTH OF MASSAC14USETTS
// Board of Health, I MA.
Appl16tio for a Permit to Cgltstruct() Repair(
Location U 1 Cu�'%p s
Map/Parcel# AM
Lot#
Installer's Name t &)Wi� fT C
Address V-3 r
Telephone# s Cf C01)
Type of Building �y,� t
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min.required)
Plan: Date S/ 31 / 14,
Title /V�jifd C�
FEE`�"'�
Ot:0-2411
q PERMIT
I Individual Components
�1,75
Size sq. ft.
Garbage grinder {
_ Showers ( ), Cafeteria ( )
gpd Calculated design flow �yS Design flow provided - `r gpd
Number of sheets _ Revisioi),Date ,
Description of Soil (s) 3'eP S°'' I 1 n V ,�,
Soil Evaluator Form No. Name of Soil Evahiato�'j���� Date of Evaluation �— �!/F
The undersigned agree to install the above described Igdividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o place a syste ino ti a Certificate of Compliance ha been issued by the Board of Health.
Signed i DateJG��
Y '
No. C 40 (O
16
i
COMMONWEALT14®F I�[1 ASSACHUSETTS,4
Board of Health, 1%A a A4 1 t� jet , MA.
CERTIFICATE OF COMPLIANCE
V4 �y
Description of Work: 0 Individual Component(s) 4a'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,,y .�andoned ( )
at L+ /3 t, a i !' C r r G l `' S Gc.l T4 k, lv7 d'J - -- ---
has been installed in _accordance with the provisions of 10 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer i� i a I � pa -c- ! �y i'J i�c . / ti 1� t) C e--L.l_I C
Designer: Cknr . /'q�spector: ��G � Date: % "�� %%(®►
The issuance of this permit shall not be construed as a guaran e6 the _system will function as designed.
Y
No.FEE
& COMMONWEALTH OF MASSACHUSETTS c - 2-111
!t Board o Health i Tisk- MA.
f �v �-�
6-- DISPOSAL SYSTEMCONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Re aif( ) Upgrade (Abandon an individual sewage disposal system
at
as described in the application for
pSysteml ! F 7, /
Disposal Construction Permit No. dated
Provided: Construction shall be completed within of the date of this permit. All local conditions must be met.
Form 1255 Rev.. 5/9966 A.M. Sulkin Co. Chadeslown, MA Date % !' Uig /Board/o�f Health
46�11)1(1 / v' .1 ir./� sf"1 ��.� .2.> i✓ f""f /"I/�'..Y../��i�Gam% dJhF3:. Je"�