HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6 CA -7 ` '_q
FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade4ol/Abandon( ) - LlComplete System -a ., vidual Components
Location S' Day) 0 -e -,Q o, kiw I 4Ctr1qCyWJ4)Owner's
Name Cb -'L1,5 -f
Map/Parcel# [ 4 3
Address
Lot#
Telephone#
Installer's NameI1 s rim J)4nj
Designer's Name �Q(� J�-1 jt YJ �5r� % L�
ncc'n
Address a3 ♦ h �� , r� t4
n
dress /0- o , /n� V'I.&,.3 , J'C'i.G; OP-4
Telephone#
Telephone# `�C�- SSD y &-%
Type of Building 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) s � gpd Calculated design flow 2 Design flow provided J, d
Plan: Date C l �"i 3,91 Number of sheets t Revision Date
Title
Description of Sbil (s) _
Soil Evaluator Form No
Name of Soil Evaluator 7-1-11A if ew Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agree ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to Fpl the ystem ' o on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections J,--`
J �
No. 'K�, i.,) C -' '� -110 FEE -=
Board of Health,MA.
CERTIFICATE Of COMPLIANCE
Description of Work: @@Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded bandoned ( )
by: ` I k J i"U ; i Co')9- -
�i�
at 5 10, 4_.P ��" 4,414,
has been installed in accordance with the}�rovi ' ns o X310 LMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated f " Approved Design Flow pd)
Installer Crs 2E
'`t
Designee: i_ ✓1 k N- ,;7.'i" Inspector: r -rP ;.�_
Date: -3 213
v
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. T t :) � j l -� �� '� FEE.: ,
q__/T CONI MONW LTII OF MASSACHUSETTS �2 � ����
Board of Health, ? d; i1 MA.
'STEM CONSTRUCTION PERMIT
DISPOSAL S1
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(<Abandon ( ) an individual sewage disposal system
at r ✓' '` ti ' ,moiCi4 as described in the application for
Disposal System Construction Permit No. dated
r.
Provided: Construction shall be completed within 4hxcE a`r`s"oithe date of this per l local conditions must be met.
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Form 1255' Rev. 5/96 A.M. Sulkin Co. Chadeslown, NA Dat Board of Health ^�