HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,f/ ;� 7 0Q,16 f
/7-00 COMMONWEALTH OF MASSACHUSETTS
FEE
' Board of Health, `J 0 jTW , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Ap lication for a Permit to Construct( ) Repair,(/ Upgrade( ) Abandon( - Ll Complete System'�Q ivi
Inddual Components
ocation o j-4 S -t Owners Name (2,
Type of Building RC--S't'CA zM ,t 0- 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) Z Z O gpd Calculated design flow Design flow provided 3 L 0 gpd
Plait: Date 1-13-111 Number of sheets 'L Revision Date '1 • Z j ' In
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS .D OOX - 10 j4Q 29 14f-0.—)CDr S
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not toplace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed I�_Ai �I d to i Date
Inspections
No. / 7 �.•�� FEE7-1�b
COMMONWEALTH OF MASSA HUSETTS r 7F
Board of Health, A M 0 t A _, MA.
CERTIFICATE OF COMPLIANCE o
Description of Work; @4ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (uelUpgraded ( ), Abandoned (
by:=—moi r_ It C e �o� ✓�
at t ► -�n rte. ,�
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. dated Approved Design Flow (gpd)
Infitaller R ;� A4 r1A 2 -, t,-. -i (n
Designer: k'1.12- (. j42rK Inspector: 444-1.9 Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FNo. L� i 7 - v� " / EE
/7--�q 6 COMMONWEALTH OF MASSACHUSETTS
Board (f Health, _ N&.O( M4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( vo� Upgrade( ) Abandon( ) an individual sewage disposal system
at-_�i��� Sn i c,Q err ti} as described in the application for
Disposal System Construction Permit No. dated � % �!
Provided: Construction shall be completed within three years of the date of this perxpit U1 local con itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesiown, MA Date Z �'1/ pard of Health
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Map/Parcel#
Address O 5+
Lot# G Z
Telephone#
Installer's Name ¢r
X �� J0. j p,�
Designer's Name £'Ov tA)pT-k S
Address 1[4 —r�� C.
LAS
Address Z er'OSS 'e.) of
�Telephone# oy3
Telephone# t�
Type of Building RC--S't'CA zM ,t 0- 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) Z Z O gpd Calculated design flow Design flow provided 3 L 0 gpd
Plait: Date 1-13-111 Number of sheets 'L Revision Date '1 • Z j ' In
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS .D OOX - 10 j4Q 29 14f-0.—)CDr S
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not toplace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed I�_Ai �I d to i Date
Inspections
No. / 7 �.•�� FEE7-1�b
COMMONWEALTH OF MASSA HUSETTS r 7F
Board of Health, A M 0 t A _, MA.
CERTIFICATE OF COMPLIANCE o
Description of Work; @4ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (uelUpgraded ( ), Abandoned (
by:=—moi r_ It C e �o� ✓�
at t ► -�n rte. ,�
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. dated Approved Design Flow (gpd)
Infitaller R ;� A4 r1A 2 -, t,-. -i (n
Designer: k'1.12- (. j42rK Inspector: 444-1.9 Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FNo. L� i 7 - v� " / EE
/7--�q 6 COMMONWEALTH OF MASSACHUSETTS
Board (f Health, _ N&.O( M4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( vo� Upgrade( ) Abandon( ) an individual sewage disposal system
at-_�i��� Sn i c,Q err ti} as described in the application for
Disposal System Construction Permit No. dated � % �!
Provided: Construction shall be completed within three years of the date of this perxpit U1 local con itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesiown, MA Date Z �'1/ pard of Health
r"l ,