HomeMy WebLinkAboutApp-Permit-ComplianceNo. -7-651,3 kmz � t V ` FEE
COMMONWEALTH OF MASSACHUSETTS
fiell Board of Health, )�MW t , MA.
PPLICATION FOR. DISPOSAL S TSI CONS UCTION PERMIT
(
Appli ation fo a Permit to Construct( ) Repair( ) Upgrad Abandon - omplete System U Individual Components
tl;
CJS
0
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
gpd Calculated design flow U Design flow provided 5(a 0— gpd
Number of sheets Revision Date
Description of Sbil (s) V1 ee1A& 2
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 agr s to not to place the system in operatio ntil a Certificate of Compliance has been issued by the Board of Health.
Signed U ate_ ,2�2--d- Date
No. 5' 0VkbC47-05
COMMONWEALTH OF MASSACHUSETT
::Board of Health, VI,M4 ' MA'241
A Of COMPLIANCE
CERTIFIC
Description of Work: ❑ Individual Component(s) Evb�bmplete System �J
The under si ned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (-;�bandoned ( )
by. 1'Aa
.
at ' s`
has been installed in accordance with the provisions of 310 CMR 15.00 (T' e 5) and the proved design plans/as-built plans relating to
application No. j .9r dated �' _ Approved Design Flow (gpd)
Installer 1A .� 1/ G' _ 9�- %i'1.a . s a .� _ i f �3
Designer: ]Ce -,i
Inspector:
The issuance of this permit shall At be construed as a guaj
Date: '4i
that the system will function as designed.
-- _
COMMONWEALTH Of MASSACHUSETTS
Board of Health, M.A.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
r
FEE �' )
2 -
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ),an individual sewage disposal system
at �% 1 r o. as described in the application for
Disposal System Construction Permit No. i ,;, dated / r�
Provided: Construction shall be completed within three years of the date of this pe All local conditions must be met.
j Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Date f ! ✓ Board of Health L �
A e A/ !`i ! A.,/l �1,0 r' J {�!°. A.�IG�Soi'��� _� Y"����d l�l�/.�L-3, '4,V -Al
Location 7
Owner's Name
Map/Parcel# (ZZs, Z
Address 7
Lot#
Telephone#
c .r
Designer's Name
LInstaller'sme
AddressJL'�
3 _ ���
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
gpd Calculated design flow U Design flow provided 5(a 0— gpd
Number of sheets Revision Date
Description of Sbil (s) V1 ee1A& 2
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 agr s to not to place the system in operatio ntil a Certificate of Compliance has been issued by the Board of Health.
Signed U ate_ ,2�2--d- Date
No. 5' 0VkbC47-05
COMMONWEALTH OF MASSACHUSETT
::Board of Health, VI,M4 ' MA'241
A Of COMPLIANCE
CERTIFIC
Description of Work: ❑ Individual Component(s) Evb�bmplete System �J
The under si ned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (-;�bandoned ( )
by. 1'Aa
.
at ' s`
has been installed in accordance with the provisions of 310 CMR 15.00 (T' e 5) and the proved design plans/as-built plans relating to
application No. j .9r dated �' _ Approved Design Flow (gpd)
Installer 1A .� 1/ G' _ 9�- %i'1.a . s a .� _ i f �3
Designer: ]Ce -,i
Inspector:
The issuance of this permit shall At be construed as a guaj
Date: '4i
that the system will function as designed.
-- _
COMMONWEALTH Of MASSACHUSETTS
Board of Health, M.A.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
r
FEE �' )
2 -
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ),an individual sewage disposal system
at �% 1 r o. as described in the application for
Disposal System Construction Permit No. i ,;, dated / r�
Provided: Construction shall be completed within three years of the date of this pe All local conditions must be met.
j Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Date f ! ✓ Board of Health L �
A e A/ !`i ! A.,/l �1,0 r' J {�!°. A.�IG�Soi'��� _� Y"����d l�l�/.�L-3, '4,V -Al