HomeMy WebLinkAboutApp-Permit-ComplianceNo. j3W DC -17-00 (- � 1 N, DT (�-_. I O - Coos J l FEE ' S v do
17-1e COMMON EAL Of MASSACHUSETTS 63
Board of Health, �-` a " C li5k3 MA. /
APPLICATION FOR DISPOSAL SYSTEMS CONSTRUCTION PERMIT -T-�2
Application for a Permit to Construct( ) Repair(JrUpgradeO Abandon( - ❑ Complete System X1,dividual Components
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Owner's NameLocation
O GInUf1 � 0.+^
Map/Parcel# (08
Address L cr cfrv�c�
Lot#
Telephone#
Installer's Namc B F (3
Designer's Name
Address cafe ` Oi"
Address
Telephone# Sog.el -
Telephone#
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Type of Building Lj2Lot Size sq. ft.
Dwelling No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers( ) , Cafeteria ( )
Other Fixtures
Design Flow (mina required)
Plan: Date
Title
Description of Soils) _
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS KC�Mr--M 0-S'
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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 RK-G� M�Qq, Date `i - 2'? - J Tl
COMMONWEALTH OF M ASSACHUSET
e-57\--
Board of Health, — MA. 0�oy'4
CERTIFICATE OF COMPLIANCE
Description of Work; 94ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired („)'O"Upgraded ( ),A n�c on
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at 64 Mxqice! 0-a1r a�' "!!m !"r zx C '
has been installed in accordance with the provis ons of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated - .i fL/ i . Approved Design Flow (gpd)
Installer j'6. C>
% v
Designer: Inspector: Date: 7''l / -
The issuance of this permit shall not be construed as a gua tee that the system will function as designed.
FEE
7- f COMMONWEALTH Of MASSACHUSETTS
Board of Health, 01 jn MA.
DISPOSAL SYSTEM- CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( %4' Upgrade{ ) Abandon ( ) an individual sewage disposal system
at �, , Pr- t` ""� l"� - as described in the application for
Disposal System Construction Permit No. 7- /C1 , dated. 7,26-"7/ 7 a
]Provided: Construction shall be completed within -f , ears tth�e date of this permit. All local conditions -iust be met.
Form 1255 Rev. 5/96 A:M. Sulkin Co. Chades(own, MA Date r/` !Board of Health
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