HomeMy WebLinkAboutApp-Permit-ComplianceNo:
COMMONWEALTH Of MASSAC14US TTS
Board of Health, �Y_ �1 MA. T r — 17-6o Sg s,S
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepaiLC*iDpgrade( ) Abandon( ) - ❑ Complete System Wndividual Components
Location S ljk4� ka e A
Owner's Name t
Map/Parcel# L 61 %6 40 '?A—
Address ,J(.24,41
Lot# y.: -1
Telephone# %71-674 G �j
Installer's Name r Ke e L t j
Designer's Name N
Address Pv�� a L� �/�l1� 187A
Address
Telephone# SU -7 )6 - , c
Telephone#
Type of Building Re 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 gpd
Pian: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS r(rA 6- C., SSPar ► X41 A, /41%
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 C mpli ce has been issued by the Board of Health.
Signed /Date l 3 .
r
Inspections
No. Y i r �' l' ` /'% J`EE
C®MMONWILALT14 Of MASSACHUSETTS
Board of Health, MA. ,}, to
CERTIFICATE Of COMPLIANCE � Z ,
2�
Description of Work: individual Component(s) ❑ Complete System j!r{
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (Abandoned ( )
by: i (e m- L,,,A i,. ritY.x A
at S' AAmei-" lt:'t^ ,
has been installed in
application No.
Installer _A,_
orda ce with the provisions of 31D—,CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated -- '—/./Approved Design Flow :?,-(gpd)
Designer:, Inspector:_Date:
The issuance of this permit shall not be construed as a guartee that the system will function as designed.
No. Q"G �i`i 1., FEE_.0�
7-
COMMONWEALTH OF MASSACHUSETTS
Board of Health, yj/��i_�, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repai Upgrade( ) Abandon ( ) an individual sewage disposal system
at
Disposal System Construction Permit No. 'dD , dated
as described in the application for
Provided: Construction shall be completed within tb�'s otf Yi�e date of this permit i local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date ` �' oard of Health e%