HomeMy WebLinkAboutApp-Permit-Compliancet GD IV— I-2—IJ0Z 316-� FEE 110 100
COMMONWEALTH OF MASSACHUSETTS G�t-�!
Board of Health, MA. t
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(A/Repair( ) Upgrade( ) Abandon( ) ecomplete System ❑ Individual Components
Location
Owner's Name LC C
Map/Parcel# 3 p
Address C3�y
Lot# +� �}
Telephone#
Installer's Namer - r---� C
Designer's Names ,
Address sxrjus ` ��
Address a3
Telephone# w
ITelephone# 2 ,
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Datelrttroj/ -oa3.c
Title
'96)� s° 5" ' gpdPCalci.
Number of sheets
design flow
0
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Design flow provided J!�/, V gpd
Revision Date
Description ofSoil(s) SJ
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to ' th above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t ace ystem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed r Date
, R
Inspections !' —17 41Y ML 6LL
v`
No. r.=1(0_�-7
EE f �+ . 00
- C®�'I[MONWEA.TII OF MASSAC14US ETTS y -ter `7 s I
Board of Health, Y _ O I M4 MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired ( ), Upgraded ( ), Abandoned ( )
by: A6(L11.4,4-'! =yr,j,=4(�4c �e
gyp- —r -
at j ql. �/CC,
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. i "�� dated Approved Design Flow lei (gpd)
Installer _ ltf I , KI 44";' e • i2l�offl r 71 P.,S) IDL -0-M
Designer:54 f1i 9 r4 ,.A j i.,fir, :.,7��14
r Inspector: � � � �1� Date:
The issuance of this permit shall not be construed as a guars a that the system will function as designed.
No. gOt IDC-t6—k";09
CSE i.� C l p
t CO�1[I�I®NI.T�I MASSACHUSETTS
Board of Health, VA 0 t M MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE ,
f k ( Z.( -(c2 Zw
Permission is hereby granted to; Construct( ) Repair kUpgrade( ) Abandon( ) an individual sewage disposal system
at(�_�'rx c v, �- as described in the application for
Disposal System Construction Permit No/ r , dated
Provided: Construction shall be completed within Lbxaa r''o` hTe date of this permit. All localon 'tions must be met.
Board of Health
Form 1255 Rev: 5/96 A.M. Sulkin Co. Chadestoivn, MA Date L