HomeMy WebLinkAboutApp-Permit-ComplianceNo.. ft" -!D C-7-350 aO
i-/- o
FEE
S
Co ® LTH ® srCiJSETTS
Board of Health,
APPLICATION FOR DISPOSAL SYSTEMCANS RUCTI®N �
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - omplete System ❑ Individual Components
Location -s�0%i(7 L O �i
Owner's Name I-Pea5p'1-0
Map/Parcel#' ayiAr
Address
Lot#
Telephone#
Installer's Name yyf®
Designer's Name le?
Address e' .� G J %
Address
Telephone# tf"O 6P ,7-s"
Telephone# 367
Type of Building ��`'�' 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) O gpd Calculated design flow c .4✓ 3 Design flow provided gpd
Plan: Date -'00'07 ' cV -/— -0`0d Number of sheets .9 Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
�' ®�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t to pl ce the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed / Date .?
Inspections
„ . No. � ��..�✓ C '" I JT ._'C� FEE
COMMONWEALTH OF MASSACHUSETTS.64/ r� � � � �j-7
Board of Health, Xaamo Ln MA'
CERTIFICATE Of COMPLIANCE V � � 4
Description of Work: ❑ Individual Component(s) omplete System (,T -
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ),'Upgraded ( ), Abandoned
by: LT� o "/ Z 'd,4C9
at
has been installed in accqLdaQce with the provisions of 310 CMR 15.00 (Title 5) and the
application No. 1-7— , dated" f7Approved Design Flow
design plans/as-built plans relating to
nsta er
Designer:0&'s+tr'✓"' �`� P. Inspector: �' Date: �
malzae
The issuance of this permit shall not be construed as a guarantee that the system function as designed
v� •�� .._, �� .. i,'C-F cC _ _ �ff . r';cam c ..�C.
No. t 1Q 11 r - % " ':� l o1 -ti 7 . E C, FEE ...
COMMONWEALTH OF MASSAC14USETTS
Board of Health, Y&Oko LM4 , M1 •
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrad Abandon( } an individual sewage disposal system
at _� d�/l.r+'` as described in the application for
Disposal System Construction Permit No./ > dated--?—,/;—/ 7.
Provided: Construction shall be completed withinVrre"ea�f the date of this ermir. p�1 local conditions must be met.
P p,�.. ice' -i ..-,
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date
^ Board of Health —�^