HomeMy WebLinkAboutApp-Permit-ComplianceNo. l�(? _ 00& G FEE $S57�o0
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600c-16407Sa 1�t81
COMMONWEALTH OF MASSAC 14USETTS
Board of Health,, MA. ARMOUrk
AfRiCATION FOP, DISPOSAL SY T CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeA Abandon( ❑ Complete System 0 Individual Components
Location Y13 PAMR±
RD QAQJ Owner's Name o &nQ.
Map/Parcel#,
Address 14 , W Lf-6rmpc6l�
Lot#
Telephone# _ 69a — ,5
Installer's Name
7n C Designer's Name -00")o eft -XC
Address 13,d
-be ii,j1 A Address 93,kfWi17a— rnio u t� (�--
Telephone# 6Z
—,�, 3 Telephone#12 P (/
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3-30 gpd Calculated design flow Design flow provided gpd
Plan: Date �/ 9 /;Q0 I Number of sheets Revision Date
Title 11 i (kNi?- f Tl
Description of Soil (s) _
Soil Evaluator Form No.
OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
WRIMM
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 t the m �ri bperatlon until a Certificate of om liance has been issued by the Board of Health.
Signed x• t r Date .�
r Inspections
C®MMONWELT14 OF MASSACHUSETTS
ETTS
FEE S3 � tX)
Board of Health, 0 OR ; MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) A Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded (��, Abandoned( )
A,,
by:
at
has been installed in accordance with the provisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application f(No. /C � dated f� Approved Design Flow ��(gpd)
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Installer PAM c"tnr�, --:Cn r RAxrR-(C.tc. K,
Designer: I) 1 " Tn C Inspector: `- t✓' �Gl �' Date: _
The issuance of this permit shall n t be construed as a guarantee that the system will function as designed.
A
& o' COMMONWEALTH OF MASSACHUSETTS
Board of Health, YAg. j. uU M MA -
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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FEE T57• `it f r---
CA*&t $i
Permission is hereby granted to; Construct( ) Repair( ) Upgradek) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. ' % dated
as described in the application for
Provided: Construction shall be completed within-4rree-w-" of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sul��kin Co. Chadestown, MA ` Dat C� �j� //41B
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