HomeMy WebLinkAboutApp-Permit-ComplianceNo. lel �� O't/V f�FEE
COMMONWEALTH Off' MA e c fffU ��� 01393r7Z� '
FOR
of Health, YAg /�� , MA.
APPLICATION FO DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair46 Upgrade( ) Abandon( ) - 01 Complete System ❑ Individual Components
Location 99
Owner's Name r ) l
Map/Parcel#!�
Address S 'St-.
Lot#
Telephone# Jag .. 23,5 --
%, i -Installer's
Installer'sName�U S
' C Designer's Name. i ? '
Address S
1,Jl5 045 Address wwaz WV
��®•? �-
Telephone# 6,rs- —ssf d4.
Telephone#
Type of Building Lot Size ���``� sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( }
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures p
Design Flow (min. required) gpd Calculated design flow Design flow provided VV)( gpd
Plan: Date Ui 3� Ui'�i Number of sheets / Revision Date ,�t3� l q, ad t
Title / >"�i� �' �i �-e Pi all 4 w 0 0/ 50• yKxf
Description of Sbil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
of Soil Evaluator
Date of Evaluation
The undersigned agrees to ins bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not top ystem in operation until a Certificate of C mp lance has been issued by the Board of Health.
Signed Date 46 l n
Inspections
No. > R 1 f "t 14 FEE Y" C0
COMMONWEALTH ,OF MASSACHUSETTS
Board of Health, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) C"Omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired,(i ), Upgraded ( ), Abandoned ( }
by; h✓is t_f s �r't i' S n;p
at
has been installed 1— accordance with the rovisions of 310 CMR 15.00 (Title 5) and the a roved design plans/as,bulil>,plans relating to
application No ��T "_.�" dated o !. Approved Design Flow (gpd)
Installer try
Designee-Anawl C r? Inspector: K•%- t"s Date: / I
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. f
No.�t41i
FEE.+ iC1
COMMONWEALTH OF MASSACHUSETTS
Board of Health, \144M.01 MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair• Upgrade( ) Aband
?n( ) an individual sewage disposal system
at / r ¢ ti C as described in the application for
j I
Disposal System Construction Permit No. dated 2__,� L/.7
Provided;' Construction shall be completed within three�'ec. of the date of this permit. All local conditions must be met.
Porn 1255 Rev. 5/96 A.M. Sulkin Co. Chadesiown, MA Date S Board of Health