HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,d VC-1�-zoevs, FEE
6- 32 COMM ONWEALM OF MASSACHUSETTS
Board of Health, Y-4e=MoL,r7,+ , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(/R pair( ) Upgrad ) Abandon( ®'Complete System ❑ Individual Components
Location/j' (°e,j ����
Owner's Name CjN
Map/Parcel# /,2 3
Address /a-/
Lot#
Telephone#
Installer's Name
Designer's Name �fL'
Address �0. VuX /� (0 V- �,�K.
Address 3,Yi l@u k 2,,e 0--l'-9 fN
Telephone# nl - 7.37- '�71
Telephone# i -7P- f 9/
Type of Building Re,-. 1 a f G
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
Lot Size /�; /9'? sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plana Date /2-/71/1. Number of sheets / Revision Date
Title •f 2,se
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator �'f Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Ale -0 V e� YSc fv ✓ f�v�
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.
Date
Signed ii: ZZ�f
r
Inspections
No. G 4 V--1(" 20 ! .J ( u {�}�7���(`, � j( 7(�( d i f ' �T FEE i%`J . 00
'1..OMMO1�Y V'W EALT14 OF MASSACHUSETTS ChA t'ti 9,5
a rd6f Health, .< MA.
,f CERTIFICATE Of COMPLIANCE
Description of Work; ❑ Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (Y), Repaired ( ), Upgrade andoned ( )
at
has been install' a c or with xhe visions, of 31 CMR 15.00 (Title 5) an the roved design plans/as-built plans relating to
application No. -� dated --2' Approved Design Flo (gpd)
Installer A) A, t,/ W N kTrE e A\ -
Designer:
1_
Designer: SIC z Inspector: 14,-y ✓vy d'M 1w'-1 1 a 1-17-17
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 66M)C'_Ko-2-09"�"' M C�NgSc pl�Cr- FEE . 00
A - `�%�-'� COMMONWEALTH OF MASSACHUSETTS Ck-#
Board of Health,jf2 D i, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( Repair( ) UpgraQ51,-)-�bandon( ) an individual sewage disposal system
at Cr ('e n J�,' /Orr f I as described in the application for
Disposal System Construction Permit No. f , dated 5--D i7'
Provided: Construction shall be completed within tirree-�o thf eie dof this All loco c ditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date / �oard of Health