HomeMy WebLinkAboutApp-Permit-ComplianceNo. -~��� •!JU✓ "��Y `,� P I �D�((f l� FEE 4bc7:Oa
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COMMONWEALTH LTH ®F M CHUSETT �
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Board of Health, A� - - , MA.
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APPLICATION FOR DISPOSAL SYSTEM CON RUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (�bandon( ) Complete System ❑ Individual Components
Owner's Name A�fLocation iJ{
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Map/Parcel# S 7 l�GifL
Address �Jp
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Lot#
Telephone# b i� _ J4 % 9 Z
Installer's Name �-�
Designer's Name boygn
Address % f %
Address
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Telephone# 6t9k- .4
Telephone# 'tog -
Type of Building - 1 1,4 zwl &,L Lot Size sq. ft.
Dwelling - No. of Bedrooms 1- - Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mij. req ired) :3 :3(gpd Calculated design flow Design flow provided gpd
Plait: Date i Number of sheets Revision Date
Title
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Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator P rru e I Date of Evaluation -5 z
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DESCRIPTION OF REPAIRS OR ALTERATIONS 5-0 T / / Z o !a (z WS
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The undersi ed a ees to install th ove des ibed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a s 3t t lace the to tion until a Certificate of C9m� been issued by the Board of Health.
Signed Date 0
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Inspections `5
No. &1412( '" 1 7 ""`7"ts49 c;,, COMMONWEALTH OF MASSACHUSETTS FEE
Board of Health, Ute_ r�0 til I , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 2-150mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired( ), UpgradedAbandoned ( )
Uy:'
at 250
has been installed in
Installer
design plans/as-built plans relating to
Designer: L) 1) ,j CN (('G. _ �� Inspector:. C " —/ Date: _
The, issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE
COMMONWEALTH ,®F MASS C14USETTS
Board (f Health, 0 , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
atI 1 1 l i i ? 11 as described in the application for
Disposal System Construction Permit No. 17 1 dated 6-q-17
Provided: Construction shall be completed within threeyearsof the date of this permit. �Alllocal cond'tions must be met.
Form 1255' Rev. 5/96 A.M. Sulkin co. chaaeslmvn, MA Date % r' Board of Health f� /
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