HomeMy WebLinkAboutApp-Permit-ComplianceNo.WX-Ro-440-7 &-Y/I 'I7`06'-7,"qq FEE $Sr,00
/ COMMONWEALTH OF MASS C14USETTS U414 qSSZ
Board of Health, )(Aa6oun4 , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Q6) Abandon ( ) - ❑ Complete System Oludiidual Components
Location
Owner's Name-/�
Map/Parcel# �� 4��
Address rzl-
Lot#
Telephone;,
Installer's Name Z -
Designer's Name jcr
Address�� fj�s
Address A��
Telephone# - t�
Telephone# 15-4;62 �4 j
Type of Building� 6 Lot Size/6�d.6 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other- Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures m
Design Flow (min. required) &0- gpd Calculated design flow Design flow provided gpd
Plait: Date &! Number of sheets
Title
21
No. Jost c"�)aCJO—Wol
FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, VA- 2-AA4 j J , MA.,
_ CERTIF ICATE. ®f COMPLIANCE
Description of Work: ndividual Component(s) ❑ Complete System
The andned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedf , Abandoned( )
by: //-,
at
has been installed in
application No g
Installer `.dam r e
with the provisions of 310 CMR 15.00 (Title 5) a d the roved design plans/as-built plans relating to
dated .'Approved Design Flow (gpd)
4
Designer.Z21�::W� r,. Inspector: ya - — Date:` 7
The issuance of this permit shall not be construed as a guaran ee that the system will function as designed.
e
FEE -
/` - COMMONWEALTH OF MASSACHUSETTS Ck1-# 45 282-
Board of Health, \/A ij n 0n+ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby grantedto; Construct( ) Repair( ) UpgradeX ) Abandon( ) an individual sewage disposal system
at 33� 441 /; as described in the application for
Disposal System Construction Permit No. ° dated tel!
Provided: Construction shall be completed withinkweare date of this permit11V-1. All local cotuitions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 41 ' -,,,-$oard of Health t+