Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceNo. jo W,0C-1(-[q Z2 L�440-74 � t7 FEE Ot7oO0 / d-n'1[X'l[®XjW T.TH d -)r X4ACCA d-TITTTQFTTC X3 Board of Health, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repairx Upgrade( ) Abandon( ) - ❑ Complete System kIndividual Components Location 19,gaOU C—JSUNrr 7Z Owner's Name �, /� a Rf7R6s3lTie�'F� �Nt? Map/Parcel# Lob3 Address i a t0N G Lot# Telephone# Installer's Name A AgLot 0 E Designer's Name N /A Address t 53 S�i- Address Telephone# Telephone# r Type of Building PROyegS t©lvaf {, fO e� ss oc, Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder( } Other- Type of Building No. of persons Showers( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description ofSoil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t not ace the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed i Date fes, 3 d-G!!� , Inspections No. FEE COMMONWEALTH OF MASSACHUSETTS f Board of Health, Y&Vwoov , MA. GV CERTIFICATE OF COMPLIANCE .Description of Work: ATndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired )Q, Upgraded ( ), Abandoned ( ) by: C A R et-e.'n GQ" 15 U—d at "1� Q D c! TP'c 1 R V tV E"f '? has been installed in accQrdance with the provisions of VO CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated 2 ? la . Approved Design Flowr � � ` (gpd),. Installer (C "�t � Ce- , } Designer: NJIA Inspector: Date: / The issuance of this permit shall not be construed as a guarantee that L system will function as designed. No. �(� �-^ CRip i °! FEE`` . l COMI®N�LTH OF MASSACHUSETTS Board of Health, 0 fLQ4 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(X Upgrade( ) Abandon( ) an individual sewage disposal system at -�Ra OO -7"i= aM' WJ t fi ®i as described in the application for Disposal System Construction Permit No., dated Provided: Construction shall be completed within tie rs of Ke date of this permit. All local conditiggs, must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Date Board of Health,%%C/