HomeMy WebLinkAboutApp-Permit-Compliancer j�elvli -#. 7 --coca �'7
No. � C�—(b -'Ig y q FEE �/
6 // COMMONWEALTH OF MASSAC USETTS ck,*073
Board of Health, a r-y"'t � � , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - Complete System 0 Individual Components
Location
157 C cJ-ifit' -^ t-C4/,,,z
Owner's Name
Map/Parcel#
'22 — i`3 i
Address P 6,
Lot# Lor-
iZ Ptrcra Z7k i•73 Pb 3
Telephone# Di7S't�
Installer's Name
Designer's Name .�-
Address f' d,
/jda! / t%S �'2� �,�►� fJ j f rVl lei
Address 12 4U, CF?�S,l+ '�' �� ti t:" ho(Q tsc
Telephone# 15- l Q Z
Telephone# s'6?8 _ 31 e) z•!c, 4 fP
Type of Building t^,A n -4-./cL r Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building elA No. of persons Showers( ), Cafeteria ( )
Other Fixtures '`�f A-1
Design Flow (min. required) 3 3 0 gpd Calculated design flow Design flow provided `� gpd
Plan: Date /O/l e Number of sheets Z Revision Date
Title ged -<Ap 4-'-, s yS It rh Cj.o G ,,� de l t 4 i 4�-- bi rill
Description of Soil (s) 6-IFfit, -41 Kd `d - L1 -may, S w�9 3 tt i3� /'ALL. Soi„�yt
Soil Evaluator Form No. Name of Soil Evaluator f e cCrt W Date of Evaluation `d
DESCRIPTION OF REPAIRS OR ALTERATIONS
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree, -,to not to place the system in operation until a Certificate of Compliance
-- has been issued by the Board of Health.
Signed Date �t-C
", Inspections
J,' f
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, Vex /YMc,-j �-G%, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Q�Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,)!Abandoned ( )
by6Fr3�
at % 5- C",
has been installed in ac
application No.
Installer IJ,
uat
with the provisio s of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
dated / Approved Design Flow tj 41F,j(gpd)
im
Designer: Z(/O/ 1 Inspector: _Date: "7 "- . " /
The issuance of this permit shall not be construed as a guarU ee that the system will function as designed.
No. - _� �� �' �• %/ . RnIzol / FEE -73
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yet -" r" \" , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade(M Abandon( ) an individual sewage disposal system
at dS` �'u¢ r'' 6c" fid . yaas described in the application for
Disposal System Construction Permit No./- dated
dated
Provided: Construction shall be completed within bh a" -o h� da"e this per)nit. All local coil itions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, M Date oard of Health