HomeMy WebLinkAboutApp-Permit-ComplianceNo. 004DC-4 -6 5 7 FEE' U (f
COMMONWEALTH OF MASSAC14USETTS
Board of Health, Y"M6C , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) :RepaiW,�,& Upgrade( ) Abandon( - ❑ Complete Systema ndividual Components
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Location
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Owner's Name
Map/Parcel#Address®V
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Lot#
Telephone#
Installer's Name �. kJ C ; �? t-
Desi ner's Name
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AddressC
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Address Z�� C',urv.�v► �-Cy w
Telephone#
Telephone# �-1 3 b72
Type of Building Lot Size x'31,0 `�7 sq. ft.
Dwelling - No. of Bedrooms n i o Garbage grinder(
Other Type of Building No. of persons Showers ( Cafeteria ( ).
Other Fixtures
Design Flow (min, requ'�ired) %LI'O gpd Calculated design flow -7gc7 Design flow provided 7q Y• gpd
2J o S Number of sheets Revision Date
Plan; Date E, >
Title. "Lin S -i-^ l l
Description of Soils) Vi
Soil Evaluator Form No. Name of.Soil Evaluator K\-k,rc.e.0 e,�,) '(Date of Evaluation /1-7-o --oQ
DESCRIPTION OF REPAIRS OR ALTERATIONSI r � 2%d L t
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees =ace th system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date() " - -L0 i.- e
Inspections
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No. / r COMMONWLALT14 Of MASSACHUSETTS N P �.
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Board of Health, MA. ,
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CERTIFICATE Of COMPLIANCE
Description of Work: 4J Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired {4, Upgraded ( },Abandoned ( )
by: A.
at 4 t` '� Y"tri s , ` 'i t' C V
has been installe ii�acyrpVce with the ro 'si ns o 1.0 CMR 15.00 (Title 5) aj e a oved design plans/as-built plans relating to
application No. , , dated 7 Approved Design Flow / (gpd)
Installer i..
Designer: i' S a L-e�.` -I Inspector: _ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. T2 0 N'P C-- -7-?S-3-7 '7 FEE _.
COMMONWE-ALT14 OF MASSACHUSETTS llh"��6 46,:5
Board of Health, Ate'{ 01m , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (c-�"'Abai dori ( ) an individual sewage disposal system
at +� �f t f1 " `�' `, �' as described in the application for
Disposal System Construction Permit No. 7 , dated /
.� � 9-1'7
/ .�p .' • • ons must be met..
Provided: Construction shall be completed within three ears of the date of this e Al l co
Form 1 55 Rev. 5/96 A.M. S}}kin Co. Chadeslown, MA Date B rd o,�ealtlz
Form
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