HomeMy WebLinkAboutApp-Permit-Compliance_No:6LD.1 - 1,3 pad 17�
1$04+1)C— 18 —22A3 COMMONWEALTH Of MASS C14USETTS
FEE 1"05100
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Board of Health, 7% Cali , , AM. �, ///J�/�/�/ gel
PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PE
Application for a Permit to Construct(.) Repair( ) Upgrade/ Abandon( ) - 0 Complete System 'Individual Components
Location t4q CeaieE StrettOwner's
Name J G/1171 &r-
kava Ile -e,
Map/Parcel#
Address 5a_r l e,
Lot#
Telephone#
Installer's Name P1
Designer's Name 00 W n Ne,
9_/1
AddressAddress
i I v -
D _& 93R N)ainSf-
Telephone# .5 -
Tel _1508- 3(&a
�y
Type of Building iLf-Gl olQaHof(
Dwelling - No. of Bedrooms 3
Other Type of Building No. of persons
Other Fixtures
Lot Size sq. ft
Garbage grinder
Showers ( ), Cafeteria
Design Flow (min. required) 33o gpd Calculated design flow Design flow provided gpd
Plan: Dater o�� _ Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator tQ Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
Cl 10—IMN MIN
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 a eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
w-�
Inspections 7—(
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No.
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 51ndividual Components) 0 Complete System F"" �
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded /Abandoned(
at Ll A
has been installed it accordance with the provisions o n31.0 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No. 2- , dated %� �' . Approved Design Flow (gpd)
s
Installer Yom` r ^t"a C t �/� I r1 r_ _7. C � V- 4`'� -i')f )t ��1
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Designer: �:� lr ;' s _ Inspector: / Date: '
The issuance of this permits be construed as a guarantee. at6 a system will function as designed.
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COMMONWEALT14 Of MASSACHUSETTS
Board of Health, )j® VM , MA:.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(
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Abandon( ) an individual sewage disposal system
as described in. the application for
Disposal System Construction Permit No., dated,
-Provided: Construction shall be completed within 4ax= o 5t date of this peri'n t:' 1 local conditions must be met.
Form 1255 Re, 5196 A.M. Sulkin Co. Cha iestown, MA Date Board of Health
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