HomeMy WebLinkAboutApp-Permit-Compliance93
No. 601oc, -7- FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ypw( OkM , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ❑ Complete System Q'Individual Components
Location /®
6'eA et/
Owner's Name
El a
Map/Parcel#
Q f
Address G
c - e
Lot#
Telephone#
��, 22 'bGO
Installer's Name�•4r C
Designer's Name
Address 17C
Address -103
r .Lf,i
Telephone#
7 it —
Telephone#
p 70
Type of Building ii�PSa V. Jell � Lot Size /f R G + I sq. ft.
Dwelling - No. of BedroomsGarbage grinder ( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures 99ll
Design Flow (min. r quired gpd Calculated esign flowe� Design flow provided 7 gpd
Plait Date Number of sheets Revision Date
Title
�� IV
Description of Soil(s) C Sn. o% I %3 `� / �rc%i, S_-,
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF
J"A ci Hit, & 5-- S Lam,_.,
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 Date J ei
Inspections
No. FEE
COMMONWEALTH OF MASSACHUS
Board of Health, �j''14fZYNOUT14 , MA.
r I
CERTIFICATE Of COMPLIANCE
Description of Work: _��vidual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Y,-5.Cbandoned ( )
by: _ /: Kcr r , r �p%� Ski" �a l._11
at %44� Pae- r :24 t�CA
has been installed in acco}•dance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . Approved Design Flow (gpd)
/ y-
Instalier e2
r+
Designer: $e_! Pe ¢_st'e. Inspector: Gfy
_ _ Date:
The issuance of this permit shall not be construed as a gualyee that the system will function as designed.
/7 /'`V COMM®NWE_ALTH OF MASSACHUSETTS
Board of Health,MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE .?.'
Permission is hereby granted to; Construct( ) epair ) Upgrade( ) Abandon( ) an individual sewage disposal system
at /0 6cn4,,LA,l Car— tri as described in the application for
Disposal System Construction Permit No., %'� ' ,dated —�'
Provided: Construction shall be completed within.t�"s` o£'Che date of this per it. All local ndi ' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health '