HomeMy WebLinkAboutApp-Permit-ComplianceNo. bow—c-- JA 18 '8LX-,1R-- 17 -to 310 L
COMMONWEALTH OF MASSACHUSETTS
j� Board of Health, r/�7Q.M0 QT9 , MA.APPLICATION FOR DISPOSA�SYSTEM C PERMI1
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Application fora Permit to Construct( ) Repair( ) Upgrad )AbandonO - Complete System ❑Individual Components
Location
t/ Pi Per
Owner's Name
Map/Parcel#
)Q 0
Address
Lot#
Telephone#
Installer's Name Hie k — ry '
Designer's Name
Address
�$ C �
Address
Telephone#
y rr-
Telephone#
y
Type of Building
Dwelling - No. of Bedrooms 10
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
gpd Calculated design flow
Number of sheets
Description of Soil (s) �")
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
sq. ft.
Garbage grinc e
Showers`.Cafeteria
Design flow provided :;, gpd
Revision Date
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 agrees to not to pl{`�. a�ce
( the system in operation until a Certificate of Co nplian a has been issued by the Board of Health.
�Signed ctL-_ � Date L 7- t
Inspections
No. 0-n C _i°p' { e I /' I(�L ti FEE . C
COMMONWEALT14 OF MASSACHUSETTS #
Board �f Health, C! (j , MA. j D /7- 7u
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) c Q-1--omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, Upgraded ( ), Abandoned ( )
by: \-A, C 4� C,
at t s,a ies"t c.+.. p b . 'r"
has been installed i accorda ce with the rovisi z s of 3 0 CMR 15.00 (Title 5) d t proved design plans/as-built plans relating to
application No. dated �L Approved Design Flov (gpd)
Installer "? L
Designer: bg) . ;J k) CA -P F- Inspector: Date: _
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. b 6JAVC.,..(o-19 1ALTH OF MASSAC14USET TIS
COMMONWE
i Ti C t`i_
FEE e
Z-2 -7
Board of Health, \kMA M4: , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(-- - Upgrade Abandon ( ) an individual sewage disposal system
at \. N4 0,e w- ev IQs" w, v as as described in the application for
�p
Disposal System Construction Permit No. - dated �-
Provided: Construction shall be completed withi �rst;Fdate of this per it. All local conditions must be met.
Form 125 Rev. 5/96 A.M,./S�ulkin Co. Chadestown MA Date - f Board of Health