HomeMy WebLinkAboutApp-Permit-ComplianceNo. &0A--pC_n--43G8
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COMMONWEALTH OF MASSACHUSETTS
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Board of Health, )LAgMD T4 , MA.
APPLICATION F®P, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade Abandon( ) - &Complete System 0 Individual Components
Location a
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Owner's Name p
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Map/Parcel# -- 1
Address
Lot# 1
Telephone#
Installer's Name SC.O
Designer's Name
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Address `J O
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Address ' S C_
2
Telephone# — Q a Vc
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Telephone# So%
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Type of Building Lot Size�i 7 � sq. ft.
Dwelling No. of Bedrooms - Garbage grinder (W d
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures ?
Design Flow (min. required) __3 3 b gpd Calculated design flow Design flow provided J %• q gpd
Plan: Date �E 1� I �� Number of sheets Revision Date
Title ff t
Description of Soil(s)Q
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS \_2G;>` G,C-'- �7-_> Wx Sir. \ k, Cro' Q, o(Z,LS w \A-�
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, :S�i L\I N c� S�CC�n 4e SCS I X /O, ?S 0e'e.,A
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.
Signed S r Date q,
Inspections
No. !-;'2 FEE
COMMONWEALT14 OF MASSAC14USETTS C"
Board of Health, _Dal QQnA , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Cl Individual Component(s) Complete System
The unders^tgned hereby certifythatthe Sewage Disposal System; Constructed ( ), Repaired (r/(Upgraded ( ), Abandoned ( )
by: �X �,�-� \ t't >J*'_V 1`•-
at
has been installed in accordance with therovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _ \� dated "� Approved Design Flow LL(gpd)
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Installer Cr �-, M �` r`c n �� x" i
Designer �,\e� V-� r� �Z r Inspector�ii.G Date: �i / Z
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
No. lC�FIC: ��i"��C�'jI I�,''j'd*�`t,. FEE
Board (f (f Health,\ e M nQn=, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(k/ Upgrade ( ) Abandon ( ) an individual sewage disposal system
atT�° C_ �c�\ 1��,- t �P`-�- as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within o to date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, Ma Date, 41Board of Health y */
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