HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60+19C 19G 46-21 ' 2t
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COMMONWEALTH OF MASSAG USETTS
Board of Ilealth, 1 A "T • Q V T 1+ , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCH
Application fora Permit to Construct( ) Repair(A UpgradeO Abandon O - ❑ Complete System
FEE'
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Location 44;t -i- `74 /V/AQ(_,mif) C=
Owner's Name N�>J� l
Map/Parcel# g
Address (39 Pl (-<,p lett 7QA-f C,
Lot#
Telephone#
Installer's Name �� ��t�t �-a
Designer's Name tJIA
Address 15 Cae�tei2
Address
Telephone# g`1 —
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 Design flow provided gpd
Number of sheets Revision Date
Description of S°oil(s)
Soil Evaluator Form No: Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS TN-5%41�c "&,(-) 14 --to `
6JS'i3l,E�, S•4�v�'tol� T cgN ` rAti te- 6 u74H-r
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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 1 _ Date
Inspections
No. �()Cs ;1.1"(4B �125V.
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, d i MA.
CEDTIETI CATE 0E CAM THANCE
FEE
Aee
Description of Work: VIndividualComponent(s) ❑ Complete System.
The undersigned hereby certify that the Sewage Disposal System; Constructed( �), Repaired X, Upgraded ( ), Abandoned ( )'
by: ( "CE -a pts, � � d1<:--",a221<:--",a22�•—��rreR P&W
at 4A-491 1 JW -.AA 4 -AME
has been installed in accordaUce with the provisions of A10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. - dated Approved Design Flo/w'} � (gpd)
Installer t'APCaJIl',-�-
Designer: Inspector:�,ec YF�'i �+� Date:` v7�
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No: i t IJC ' 1 _.�� G C Pew ID
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y14e=M6J0k
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEES C)O
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Permission is hereby granted to; Construct( ) Repair(A) Upgrade( ) Abandon( ) an individual sewage disposal system
�WWMW
Disposal System Construction Permit No. dated •-2
as described in the. application for
Provided: Construction shall be completed within three years of the date of this pen 't 1 local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChaBestown, MA Date.,)----)�-A Board of Health