HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6 OWIM-1'7-433
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COMMONWEALTH OF MASSAC14USETTS YOJ
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(�AbandonO Complete System ❑ Individual Components
Location / / -e
Owner's Name j Jc e';6 6
Map/Parcel# 47
Address / -a1r—VC,,
Lot#
Telephone# 69 (P 0 - -]
Installer's Name }
Designer's Name. 10-h egni
Address !J 7-'eS•
Address x g / ert
Telephone# 509 • 4 7 3
Telephone# 4 5 q - / (
Type of Building J�Ce`�� I d -Pn cA— Lot Size sq. ft.
Dwelling - No. of Bedrooms 0� Garbage grinder ( }
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow Design flow provided 36 gpd
Plait: Date (0 (rZ (, Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation &
DESCRIPTION OF REPAIRS OR ALTERATIONS _ _ 1-5U0 7t:.rp/ c)a /1-) 1,5
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre o t place the s in o a on until a Certificate of Compliance has been issued by the Board of Health.
Signed r Date (0I g ��
Inspections
No. a N>c-1-�-4.,13(a '/r //, EE
C®�l[MON�1LT14 Of MAS HU S -
Board o Health, , MA.
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CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) U-e6mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.( - Abandoned O
by: 1 I O
ati \i L 7 r' re. 611 I � - )l
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plaits relating to
applicationN*0b T ' dated ,%7 Approved Design Flow G(gpd)
Installer 6
Designer:" (ti 1 . q l i Inspector: Date: -7:z
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
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No, f1 kbC'-l%..t!�j � / bt" 0�CA\J, i FEE �� leu
%f� COMMONWEALTH Of MASSAC14USETTS
Board of Health, Ae- MON ii'1 MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at ( �-eyf'i 1 kr)n o W �Jfi(s l�jf)�1 I as described in the application for
i
Disposal System Construction Permit N6j"(o 7
,e- d Z-, dated
Provided: Construction shall be completed within ars oryheld-ate of this perMnitl AA local condkions must be met.
Form 1255 Rev, 5/96 A.MrSulkin Co: Chadeslaxn, MA Date oard of Health r
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