HomeMy WebLinkAboutApp-Permit-ComplianceNo. �d 7��— L�
7 -- COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y&aM "I , MA. rr /��� ft;� ���� r
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Ap Aication for Permit to Construct( ) Repair( ) Upgradef/�Abandon( - ❑ Complete System irIndividual Components
w i
ocation An &A&f1
Owner's Name
�Y
Map/Parcel#i G
Address I
06 n ' ►V Y(G
Lot#
Telephone# -101
Installer's Name �I'�
Designer's Name --TY '1 S
Address
Address 1
_\ aVF
Telephone# -t tJ,
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building
No. of persons
Other Fixtures ��``
Design Flow (min. required) s11 gpd Calculated design flow
Plait: Date Number of sheets
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Lot Size sq. ft.
arbage grinder { )
Showers( ), Cafeteria ( )
Design flow provided% gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Ctkvq W�a ju ix o VEt)- t vi Y\ IL V ' X
A5W k o e 4" -?v e -
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ales to epth�e�system
.ineengion until a Certificate of om liance has been issued by the Board of Health.
Signe4 Date I 1 �—
Inspections
COMMONWEALTH OF MASSAC14US TSd� � �� �r�CA-A 10 Zel
Board ofHealth, MA. T�q t
CERTIFICATE OF COMPLIANCE
Description of Work; dIndividual Component(s) ❑ Complete System U
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned O
by:
at
has been installed i accordance with the ,p� o_v�i�s�io�ns of 310 CMR 15A0 (Title 5) at d th approved design plans/as-built plans relating to
application No. 9 dated j� Approved Design Flow (gpd/
Installer �7F{�9Y�'l> _� '_ - - �r $ PL/�i1 /or -
Designer: r- %r2
The issuance of this
Date: %/ /
fined.
No. FEE C1
/ �-- COMMONWEALTH OF MASSACHUSETTS o �
Board of Health, , MA. ( � f i �{
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissionis hereby granted to.; Construct( Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at . f�1 1.t c LCL'C -1 Iii �\fe- as described in the application for
Disposal System Construction Permit No. / �/_.- , dated CC .
Provided: Construction shall be completed within dw . �r f�[1'ie date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co, Chadesfown, MA Date'119'— % Board of Health f