HomeMy WebLinkAboutApp-Permit-ComplianceNo.Q
COMMONWEALTH OF MASSACHUSETTS
Board of Health,YEA K 01,n � , MA.
APPLICATION FOR DIS ®SAL SYSTEM CONSTRU Id
Application for Permit to Construct( ) Repair( Upgrade( ) Abandon( - ❑ Complete System
FEE iS�� (%
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Location
Owner's Name
Map/Parcel# 3
Address Cann
Lot#
Telephone#
Installer'sName��� C
Designer's Name.
Address o 1 — ,e f )4 cac171
Address
Telephone# . L .
Telephone#
Type of Building >(CSC(,�'l�hj (,.� 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) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
OF REPAIRS OR ALTERATIONS Inc e
Date of Evaluation
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 to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Sign r Date % `:Z
Inspections
No.�'� 1C •.��i "ll � l� � COMMONWEALTH OF MASSACHUSETTSFEE _�,�
Board of Health, AQ(2Mo , MA,n
CERTIFICATE Of COMPLIANCE
Description of Work: ."dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded Abandoned O '
by: .
at a r^1 e `i
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: 7, dated-�/ Approved Design Flow ---- (gpd)
Designer: 1� - y� Inspector: Date: f -A.-/ `7
The issuance of this permit shall not be construed as a guarw"e at the system will function as designed.
No. 1C-1 7 -', SS -7 6(z0 -WP l t� ( .FEE
COMMONWEALTH OF MASSACHUSETTS 144i;-7
Board of Health, V 0%- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(rade( ) Abandon( ) an individual sewage disposal system
at •ham - as described in the application for
Disposal System Construction Perm1t No. 17=1 Z, dated f
Provided: Construction shall be completed within three years of the date of this permit. All local co ditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co !Chadestown, MA Date •6.-A-3-11 Board of Health .�