HomeMy WebLinkAboutApp-Permit-ComplianceNo, I►�JpUC-� C'7L!'�3S AG�� I✓ Z, 7 FEE t_
O'1[MONWE4LT14 01' MASSACHUSETTS cb13
1- 1 oar', of Health, Yi4 kMO QTW MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct(L)/Repair( ) Upgrade( ) Abandon( ) - W Complete System ❑ Individual Components
Location
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Owner's Name
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Map/Parcel#
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Address
Lot# z
Telephone#
Installer's Name
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� 1 Designer's Name
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Address
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i Address Ruef1-!T
Telephone#
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Telephone#
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Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mien, required) 3 f gpd Calculated design flow
Plan: Date *7 Number of sheets
Title
Design flow provided .;-r10 gpd
Revision Date
Description of Soil (s) 3 G J /
Soil Evaluator Form No: Name of Soil Evaluator O 4C' I6 JDate of Evaluation lr - !i� ` `%
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees tonot to lace the system ' operation until a Certificate of Compliance has been issued by the Board of Health.
Of
Signed Date
Inspections
COMMONWEALTH OF MASSACAETTS
Board ofHealth, i ��-i:�101 , MA.
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CERTIFICATE Of CO PLIA CE /11
Description of Work: ❑ Individual Component(s) QKlmplete System rk -7,-,74 -,7
The undersigned hereby certify that the Sewage Disposal Syste ;Constructed ( ), Repaired ), Upgraded (i�Abandoned ( )
by: , re ;
at 3
has been installed in accordance with the ovis ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �r �' dated Approved Design Flow (gpd)
Installer Nil
rR sa -rie,+ ,
r/ f
Designer: .+ +� f�r'y frs _ Inspector: l Date: :7- �� r
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 6n OMr 1-7 -%.-.' FEE 5G . 0A
COMMONWEALTH OF MASSACHUSETTS C4 t0(:; 13
Board of Health, vat MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct('' Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
A��rr--�� .1�
at i t d.;�����"° pw' as described in the application for
Disposal System Construction Permit Nol '' P dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Form 1255 5ev. 5/96 A.M. Sulkiin Co. Chadeslan, MA Date 6 --22--f pard of Health