HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1O"C.—(,co— ovi Ido !> -T — / / — Co / 10-5—
FEE v�C
6- 'COMMONWEALTH ®A' MASSACHUSETTS
Board of health, MA.l�
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT/44d4/ IZ)
Application for Permit to Construct(1j'Repair( ) Upgrade( ) Abandon( ) - VComplete System ❑ Individual Components
Location
Owner's Name
CSA et_u�
Map/Parcel#l
Address0
7-1'��Vi'S
Lot# 9-
Telephone#
Installer's Name
Designer's Name
Address
Address V'S).
af)r '3 WQV4 EA-Srl-WI
Telephone#
Telephone#
5 0 _ ('}- 'Qo,) Z0
Type of Building wP—
Dwelling - No, of Bedrooms
Other- Type of Building _
Other Fixtures
N
No. of persons
Lot Size C sq. ft.
Garbage grinder ( )
Showers (_) , Cafeteria ( )
Design Flow (min. required) i gpd Calculated design flow} Design flow provided gpd
Plan: Date.A R1L t.x x016 Number of sheets Revision Date
Title
Description of, Soil (s) (✓
Soil Evaluator Form No. Name of Soil Evaluator Dr- FEU-t5 Date of Evaluation elf jl iJ1 t<6
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned a mstall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a to toce the system in operation until a Certificate of Com fiance has been issued by the Board of Health.
Signed i Date
e
Inspections
No, fQt;'l ),,JJ f_! 6 - �)--i l
/ r- 2
COMMONWEALTH OF MriSSAAUSTTTS Z.
Board of Health, --o r10 -i MA MA• �O
CERTIFICATE"OF COMPLIANCE �
Description of Work: ❑ Individual Component(s) plete System --1 OR t V
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned( )
by: A ,.s- Irlr A(3 -,,-,t) c 1 r• -n % da 1
at
has been installed in accordance with the rovisions of 3}.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /AP
" C-7) /dated/ Approved Design Flow r pd)
Installer q C""h, rpt Vw i-rLL _ n
Designer: "/�
Inspector: � Date:
The issuance of this permit shall not be construed as a gu to that the system will function as designed.
No. Ex �Lt C - A
�U COMMONWEALTH 'OF MASSACHUSETTS
Board ( f Health, V"tAj) k j:r , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE 4:!S(� O
Permission is hereby granted to,; Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at��� '1'C.�� �,�=e'�T` , as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within xlkr re' of 2e date of this permit. All local condigon • must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date / 0 ' 4oard of Health �.� ,