HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH Of MASSAC14USETTS
� '�VBoard of Health, Y N9&0 U<1 T , MA.
APPLICAT �N FOR. DISPOSAL SYSTEM CONSTRUCTION PERM, IT
�'441ication for a Permit to Construct( ) Repair( v/Upgrade(`) Abandon( - ❑ Complete System._Erindlvidual Components
1 21
�r
ocation 10 60
Owner's Name
ap/Parcel# So/O1
Address SO 0I1,V (�
ot#
Telephone# S08-400- 9000
nstaller's Name Rober.t}. B. rco " LAC .
Designer's Name Nom" E 4AQ V
ddress 026 S
Address C lI A 140
Telephone# 0 _ Z_
Telephone# J78- 501-:1 7
Type of Building F+eS a_a3rAYV_t_ Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of personsq6 Showers ( ), Cafeteria ( )
Other Fixtures 9G 5,nLZAnz,
Design Flow (min. required) 1 gpd Calculated design flow Design flow provided q 1 9 --4 gpd
Plan: Date 3--7-1& Number of sheets I Revision Date �= i
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator \JOYI
C71i7
Date of Evaluation V — 14
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 operatio ntil a Certificate of Compliance has been issued by the Board of Health.
Signed W (?7 - Date s
COMMONWEALTH OF MASSACHUSETTSC
Board of Health, ) .lN�t„1't" 'JIM.
CERTIFICATE Of COMPLIANCE
f ( ✓SEE
c 00-731 fi r ,.
n�
Description of Work: ❑ Individual Component(s) UrComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded O, Abandoned ( )
by: 4:r -In 'ut Vic-
at
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. --=1 dated =r Approved Design Flow(gpd)
Installer � i p d R OU r Lo. T R<
Designer: ir�<L nl�s. Zp ,j) pi n jrn4a_p Inspector: = Jl y;r gfgfZ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. fz— FEE
/,,6 --lo - COMMONWEALTH OF MASSACHUSETTS c it-* Dv -151 C7
Board of Health,YA-t2 ft ,1 /IA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at I') i ,1<44 k4a& ,4' S (Y f+ as described in the application for
Disposal System Construction Permit Noi1y1�� ,dated 4
Provided: Construction shall be complte` i1a1h�zear ��f �d e ofrthis permit. All local conditions test be met.
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I //'
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Dat t oar f i e� t_J�s
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