HomeMy WebLinkAboutApp-Permit-ComplianceNo. ` 6 -PQ-4872, � � —OO �p V V Ci FEE S cS" V v
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7-/,?- COMMONWEALTH OF MASSACHUSETTS ,--mak
(� Board of Health, 7.1'V101i i MA. ,✓l1 �G t,`'-2-
• /.�� fie;� /APPLICATION FOR DISPOSAL SYS- TEI CONSTRUCTION PERMIT
�licatio
n Apn for a Permit to Construct( ) Repair( ) Upgrade,(/1/Abandon(( ❑ Complete System «a`Individual Components
ocation pN AveOwner's
Name
j NNS �i%Ne
ap/Parcel# 'I8
1 1$ a
Addresso-Y4 q
O°L6(p
#
Telephone#
taller's Name i& n� S -jaLDesigner's
td
Name
�Vi h�,t�V�dress
bX Q
Address �q
S&A-ACk ,KP,
Telephone# Sb8- 3q 30
Telephone#
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) U 0 gpd Calculated design flow Design flow provided 4'6gpd
Plan: Date ' h 1- Number of sheets Revision Date
Title S &Lp
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESC•RIA70N OF VPAIRS OR
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to no to place the system in operation until a Certificate of ompli nce has been issued by the Board of Health.
Signed G 7 i Date
Inspections
No. V LI Lo " f / `4 A .. FEE li5tC1i
COMMONWEALTH OF MASSACHUSETTS
Board of Health, V", M tx i , MA
Few. O rp
CERTIFICATE Of COMPLIANCE
Description of Work: U+Individual Component(s) ❑ Complete System and �ii
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgr� e 1 o e ( )
at �1� .,10
has been installed in accorda ce with the provisions of 310 CMR 15.00 (Title 5) and t a roved design plans/as-built plans relating to
application No. dated _7- /40 1 d Approved Design Flow (gpd)
Installer
Designer: "�6��4�,�- � n Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that Ke system will function as designed.
No.
J 73 COM�'[i ONWEALTII Of MASSACHUSETTS cjf
Board of Health, Q[M* MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon(
- .� 01 , n
at
an individual sewage disposal system
_ as described in the application for
Disposal System Construction Permit No. % , dated
Provided: Construction shall be completed within t4=r date of this permit. All local con itions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadestown, MA Dat�}e 7 ! d ` / 7Board of Health �� f .✓