HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60 I+Dc- „� �� FEEO � 00
% COMMONWEALTH OF MASSACHUSETTS
Board of Health, r%�i� U, MA.
APPLICATION FOR. DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(f) Upgrade( ) Abandon( ❑ Complete System KIndividual Components
Location
1 CGS! tP Li gL
Owner's Name
- MF�-rEp- �-
Map/Parcel#
(00
Address 7l <�$1
MLx-%C—aAar-5
Lot#
Telephone#
Installer's Name s
Designer's Name
jV/A
Address
�� S�
Address
Telephone#
"ted 7
Telephone# ,
Type of Building Alla Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided 7 • pd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
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 operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 5 -Date ` R/p `v0 C
Inspections
No. 60N'D C — 1 -7-41 �3\ //Irl ""FEECOMMONWILALT14OFMASSACHUSET A
Q�
Aki &4IDBoard of Health, MA.t74 04
CERTIFICATE Of COMPLIANCE � eve
Description of Work; )(Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), RepairedA�, Upgraded ( ),Abandoned ( )
at 7/ CI 1p Lda
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
applicationnNo. G , dated �� �` �e Approved Design Flow (gpd)
Installer 1.��A-PeW mF- E..)..i7L--xm.I S,E` ,Rk".a Akb C AF --
Designer: WA Inspector:%�` _ Date:
The issuance of this permit shall not be construed as a guarant that the system will function as designed.
No. bmkbc ^" 1-7-4(63,
COMMONWEALTH OF MASSACHUSETTS
Board of Health, , MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
FEE .00
0&* o3ciq-
Permission isshereby granted to;; }Construct( ) Repair (W) Upgrades ( ) Abandon ( ) an individual sewage disposal system
at --7/ } / 1. 1 1 ? a I JU& ((®Wg- Q f A�1� 5b�.ss 4 Y/��Ll[ M as described in the application for
Disposal System Construction Permit No. h�, dated _ X. -
Provided: Construction shall be completed within three years of the date of this perm:',t. �All local conditions must be met.
Form 1255 Rev. 5196 A.M. SWkin Co. Chadeslown, MA DateBOard of Health
s'�