HomeMy WebLinkAboutApp-Permit-ComplianceNo. toQ C^ 19-2,-78q L 4�
COMMONWEALTH OF MASSACHUSETTS
Board of Health, yaam 0 U ,+ , MA.
FEE4Z—`0o f
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
plication fora Permit to Construct( ) Repairx Upgrade( ) Abandon( ) - ❑ Complete System Xindividual Components
ocation 1DX M A 4V&
Owner's Name C- AJ N (5 -51(+1100S 7-k
Map/Parcel# f r %
Address ��� _ - , n� P
V�
Lot#
Telephone#
Installer's Name GM a6 G -m
Designer's Name N
Address M
Address
Telephone# - (, f _ g277
Telephone#
Type of Building Lot Size J_5' 0 # sq. ft.
Dwelling - No. of Bedrooms Garbage grinder {
Other - Type of Building No. of persons Showers O, Cafeteria
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided' gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils) -_
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 -and
further agrees to no o lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. 0 %��.-G?�T i)� FEE
COMMON L.T14 Of MASSACHUSETTS�
Board of Health, y "7 , MA. �� �il���
lie
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) El Complete System. ! �
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired)(), Upgraded ( ), Abandoned
at j/% a M jcP t'r,J.r4•Aj-r A W:7 VA "„..'TSL_ P?-S7�--7—
has been installed in ccordae with the provisions of O CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No., , dated -?, -3 �4k Approved Design Flow _ (gpd)
Installer ';°A,b eaSt� .i714C/� _1 S' 1� ) Dle-WAZ-b __0,,&VX1i --
Designer: �Q Inspector: ti ._ Date:
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
FEE' 5 a - 00
CA 1+ 3i -7
�y
No. - SX -i 2-789 WC -0 1 'J e
, 69 COMMONWEALTH AL,TH Off' MASSACHUSETTS
Board of Health, y ID , HA:.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at 161- jW G'1_i r$14,. A )77- A t n= VA R,44 n L /`�w"�""'” as described in. the application for
Disposal System Construction Permit No. f k- 6'.P' , dated 7 -
Provided: Construction shall be completed within three years of the date of this permit. All J ,c conditions mint be met.
7•; f ,
Porm:1255 Rev.5/96 A.M. Sulkin Co.Chadeslown,MA Date-3jkard of Health �' '� r�' �l