HomeMy WebLinkAboutApp-Permit-ComplianceAW
No. f2 GWbC— -)-010 1 7I
FEE 46-r,00
COMMONWEALM Of MASSACHUSETTS M13 W4 -A
Board of Health,toQI
-ea MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repats Upgrade( ) Abandon( ❑ Complete System , Individual Components
Location ,S/U 61,1-4A VeA.I tS , �,�
Owner's Name
Map/Parcel#
Address Sf p
<r
Lot#
Telephone#-
y 0
Installer's Name ei lcc_ told C6eg4.RX4 j�
Designers Name
Address GY s° GsM o j„l
Address
G n n4
Telephone# X#e- -77j,-6'Y&
Telephone# -50"fSAT K100
Type of Building jZe�oel� 1..A 1 _ Lot Size � � sq. ft.
JI
Dwelling - No. of Bedrooms %�11xt Garbage grinder( }
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures ZZ
Design Flow (min. •equired) :530 gpd Calculated esign flow
Plan: Date %A 6 Number of sheets
Title
Design flow provided_ gpd
Revision Date
Description of Sbil(s) "o .See-
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS .1 ✓ 5 I 4Z--1-' cj - hO y 41CA '"S 9
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance h�assbbeen issued by the Board of Health.
Signed ��� Date �o�/
Inspections
No. 0 O DC r `'-b 10 }
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ..Mtn -Mm.
FEE
3(c .
CERTIFICATE OF COM VANCE O All,
Description of Work: Individual Component(s) El Complete System a'��
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repairt�-�,tUpgraded ( ), Abandoned ( )
by: o C/" L e m A i I
at 2711
has been installed in accorda ce with the provisions of »3 0 CMR 15A0 (Title 5) and the approved design plans/as-built plans relating to
application No. � � dated "/ r l /. Approved Design Flow „710 (gpd)
Installer A- conA
Designer: Inspector: ft ia16kw—,l Date:
The issuance of this permit shall not be construed as a guarantee system will function as designed.
-
-- No. i \ . c 11-010 1--1 ...
/ -7— --24 � COMMONWEALTH OF MASSACHUSETTS
Board of Health, U.J�OtLM—, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEEyj. (00
rj� 3(aZ
Permission is hereby granted to; Construct( ) Repai� Upgrade( ) Abandon( ) an individual sewage disposal system
at '� �,� leiA,,. qS° ?(,4{] ! as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within f -Re date of this p!qijut, /Aylllocalditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 14 'V Board of Health 4�
I,,