HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1TVfo �9— I-7-0 0 61-7 3
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Board of Health, MA.
APPLICATION FOP DISPOSVAba.don
STEM CONSTRUCTION P RM IT
Application for a Permit to Construct( ) Repair( ) UpgradeO - ❑ Complete Systemndividual Components
Location
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Owner's Name
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Map/Parcel#
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Lot#
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Telephone#
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Installer's Name�+
Designer's Name , a en
Address
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Address
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Telephone#
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Type of Building (0W G II t ng "` ��'r � �� — Lot Size M O� 7G sq. ft.
Dwelling - No. of Bedrooms `� Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 O gpd Calculated design flow _ Design flow provided3-78 gpd
Plaid Date s`II0 /I.-) Number of sheets 3 Revision Date
Title i J.i-LVS YAjn1mau 1reAu-
Description of Soils) eat vn /,L % /7
Soil Evaluator Form No. Name of Soil Evaluator :ani adi Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Zn S �A /'/ n• 4-W `, P- 6: e.
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to tolayoperation until a Certificate of ompliance has been issued by the Board of Health.
Signed �z �-� f Date S
Inspections
No.
COMMONWEALTH
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Board ofHealtla, VA:KM011ro MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ndivdual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded («Abandoned ( )
by: & I WKS —1� ei��,:� -'Jl '
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. -� rr dated - r r . Approved Design Flow d)
Installer U J S-aL 1" D t ` -14
Designer: Mo /1" e4JOt-) - Inspector: Az i Dater • , �` f'%'
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
No. ® / 1 G Lamer' l _f'-1-65 -f`rl�'.D J 6! FEE E
t 7-/ COMMONWEALTH OF MASSACHUSETTS i" a ®1
Board (?f Health, �r V , MA.
DISPOSAL SYSTEM STEM CONSTRUCTIO PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at `% k r f- 4 15 Ao o e- ,Y(4rYPQL, 4) as described in the application for
Disposal System Construction Permit No. Jr dated
Provided: Construction shall be completed within tree -y rs 6� ne dat�of this perm' . All local conditions must be met.
Form 1255 Rev.5/96 A.M. Sulkin Co. Chadeslown, MA Date Board of Health %