HomeMy WebLinkAboutApp-Permit-ComplianceNo, FEE
COMMONWEALTH OF MASSAC14USETTS
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• Board of Health, %%'l007V , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System D Individual Components
Location Z® IU&elllb o
Owner's Name ,e
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Map/Parcel#
Address zb
Lot#
Telephone#
Installer's Nam14 11
Designer's Nam
Age kA.)
Address ]
Address Itz
Telephone# & CI Z4<1- 1_Z Y-3—
Telephone# 7'7 4( 3
Type of Building �i �ti7 �'e �L.e et L� �Q --_-_ Lot Size
Dwelling No. of Bedrooms
Other -Type of Building No. of persons
Other Fixtures
Design Flow (min. required) 3 gpd Calculated design flow
Plan: Date 0 zw(' Number of sheets I
Title
Description of Soil (s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS &,C t&) c y07� C �Qe C?P M
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided Bio 3 gpd
Revision Date
Date of Evaluation
The undersigned adrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr to of to place the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed i Date
Inspections
COMMONWILALT14 OF MASSACHUSETTS4,
Board 0��0
Board of Health, Vd°Ll MA. /'C''//�`�,C
CERTIFICATE Of. COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certif that the Sewage Disposal System; Constructed (i"), Repaired V), Upgraded O, Abandoned (, )
by; %yoe4i�li�C- ✓15i�t�C.iL� t
at Z a /Ud,e /Z/
has been installed, in accordance with the pr visi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built:plans relating to
application No. dated •« 1 Approved Design Flow (gpd)
Installer '' Ore- C17s�i�7 E! t�� >✓t/ pit �6.�1 S� o C �� 4A..,
Designer:%iV o , A14XOZIP A4Y G i Inspector: ! V Date: `
1.. a t s
The issuance of this permit shall not be construed as a guarantee that the tem wW function as designed.
No. i n l *tiJ)l��*a 1.C�1��11-�• FEE .
COMMONWEALTH OF MASSACHUSETTS
Board (?f Health, "Al0 , NM.
µ'"`yd
DISPOSAL SYSTEM CONSTRUCTION PERMIT �� A '
Permission is hereby granted to; Construct(+/ Repair( ) Upgrade( ) Abandon( } an individual sewage disposal system
at ' eil !.> / as described in the application for
Disposal System Construction Permit No. , dated 0I i
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadestown, MA Date l C.' ! l �� Board of Health (J �� �