HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6Ot�1�C-CI- V37 �!C- 1 FEE
17-70 WMMONWEALTH Of MASSACHUSETTS
Board of Health, �a T M 0 y 4" �''� , MA.
Al PLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERM, IT
Application for a Permit to Construct( ) Repair( ) Upgrade(( Abandon( ) - ❑ Complete System >Jndividual Components
Location
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Owner's Name
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Map/Parcel#
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Address 177-
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Lot#
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Telephone#
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Installer's Name
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Designer's Name
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Address
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Address i Z, �►
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Telephone#
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Telephone#
Type of Building �-_) Ue\uk ! ,, Lot Size I b 1 73,—'5— sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building i% .l A No. of persons Showers ( ), Cafeteria ( )
Other Fixtures /'NJ 1
Design Flow (mina required) _
Plait:ate s
Title ViU>.se,0 -c
Description ofSoil (s) 0
Soil Evaluator Form No.
B gpd Calculated design flow (( Design flow provided
Number of sheets Revision Date
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Name of Soil Evaluator 4 ��' f "1 -ate of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS I-_X7.P I�. -C _ _ -��C
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The undersigned agrees to ins�,Vyt"
e�descr red Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
�fur er agrees to ce in o ttil'aFC rtific to of Compliance has been issued by the Board of Health.
ed �. a �! f7
Inspections !1 e , 7"% Z �@oI"s d 4 L
No. c -_i.-7 5,33-7 a /
COMMONWEALTH OF
SET
Board of Health, ° MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Cndividual Components) ❑ Complete System/ g
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded ( ), Abandoned ( )
at ! '�„ �-^ter-e 4 e�4:3
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5� and the proved design plans/as-built plans relating to
application No. dated — Approved Design Flow,~' (gpd)
Installer C.4A et. s^
Designer: 1-4/ !L%i/�/,&&0X; Inspector: i Date:
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
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No. '� IC- - C`
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �,��, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE. -1
Permission is hereby granted to Construct( ) Repair( ) Upgrade(A Abandon( ) an individual sewage disposal system
at �t 5�4 �-��t —
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"1T as described in the application for
Disposal System Construction Permit No. i - %�) , dated����:991G�_' ` .
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Provided: Construction shall be completed within of �i"e ate of this m' All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, Mn Date -7 Board of Health ( �-""l G� 4�1 s��' 4
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