HomeMy WebLinkAboutApp-Permit-ComplianceNo, oQc-1%-3! ( /
FEE
7- 6 COMMONWEALTH Of MASSACHUSETTS c 3� 8�
Board of Health, L&e� mo n+ , MA. //
APPLICATION FOP DISPOSAL: SYSTEM CONSTRUCTION RMIT
Application for a Permit to Construct( ) RepairV/UpgradeO Abandon( - ❑ Complete System Individual Components
Locations
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Owner's Name -off' t
Map/Parcel#
Address
Lot#
In
Telephone#
Installer's Name (' (_`
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`t: 0c• eer
Designer's Name
Address �,6 fxi,( 11`4
ilG,k s 4 4
0:,605- 5-
Address
Telephone# 5C Z`!�v
�00 7 l -7 (7
�2 2 z� 7
Tele phone#
Type of Building i e < Lot Size sq. ft.
Dwelling - No. of Bedrooms�i Garbage grinder( )
Other -Type of Building No. of persons Showers (}, Cafeteria ( }
Other Fixtures
Design Flow (min. required)gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil
Evaluator Date of Evaluation/ L
DESCRIPTION OF REPAIRS OR ALTERATIONS box. C�Iw� GV�i� j
Zb. C) $--L, y �.o 0
The undersigned a , ess'to install/die above d IndKiaual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree�s'to of to � �jm.' 'ration until a Certificate of Compli c. has been issued by the Board of Health.
Signed / �' Date
Inspections
No. ri OE�17C-I��17 FEE
J >
COMMONWEALTH OF MASSACHUSETTS 2
Board of Healthynf MA.
G
IAft Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ` l plete System sem' '1`% C
The undersigned herebyc tify that the Sewage Disposal stem; Constructed ( ), RepairedXpgraded ( ), Abandoned (}
has been installed in acc glance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relat' to;
application No. dated �/f ? Approved Design Flow (gpd) - -
InstallerC ('t Sj 0 0f
Designer: - Inspector: CS- `s Date: � r d 7
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. CJ;kU Gr (y% ^' �' / l 7} j� C O`1� S`�T 1 �C (N S P' FEE ZJ , GC
�`'' COMMONWEALTH OF MASSACHUSETTS d/z 1 °1`
Board of Health, Agftmin& MA.
DLSPOSAkSYSTEM ONSTRUCTLON PERMIT
Permission is hereby granted to; Construct(
r�) `'Repair ) Upgrade( ) Abandon( ) an individual sewage disposal system
at (ns as described in the application for
Disposal System Construction Permit No. �� �' dated
Provided: Construction shall be completed within three years of the date of this permit. Allyl local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date 3 A I ' Board of Health f; �,) ° _ �"
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