HomeMy WebLinkAboutApp-Permit-ComplianceNo. bowyC"1� U1� 1P FEE iy5 i0
-��
e
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA. � !` Z5l
^I -1 7 "1
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION rH oepr
lication for Permit to Construct( ) Repair(ZUpgrade( ) Abandon( - ❑ Complete System ndividual Components
r9S�
ocation
Owner's NameMa1czmc�m
ap/Parcel# 1 1
Address 2AJ �bd'A- � e— Yn
Lot#
Telephone# Cj_)6g x0o- -2- a I
Installer's Name {
Designer's Name - y
Address -P0 lbo�L\ �` fn
Address ?o b O'tl� RC1 n i
Telephone#
Telephone# 5ca- ZCQLj_ 04
Type of Building 79 - i6P_T)'XQA Lot Size—) 0,. sq. ft;
Dwelling- No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria ( ).
Other Fixtures
Design Flow (min, required) _ - gpd Calculated design flow_ Design flow provided_ gpd
Plan: Date�V7 Cp 1. l %7 Nuumberr of sheets Revision Date
Title ZP t
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned
further agreea'fo
Name of.Soil Evaluator Date of Evaluation
described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
operation until a Certificate of Compliance has been issued by the Board of Health.
Date i11b166
No. FE OP�(i c� W
L�
COMMONWEALTH LTH Off' MASSACHUSETTS� � � �� }—p
Board of Health, YagwoAM.
CERTIFICATE Of COMPLIANCE
Description of Work: Cldn hvidual Component(s) 0 Complete System /
The undersikned hereby certify that the Sewage Disposal System; Constructed ( )> Repaired ( ),_UpgradedAbandoned
by
at
has been installed i} accordance with the provisions o X310 CMR 15.00 (Title 5) and thea proved
application No. tt ��- ; dated Approved Design Flow(gpd)
Installer L P )kms .` 6 C)
Designer: `� l��y' ecsi Q , r Inspector:
The issuance of this permit shall not be ,construed as a,guarp
design plans/as-built plans relating to
Date;
the system will function as designed.
FEE
COMMONWEALTH OF MASSACHUSETTS
Board ofTlealt4, 624 )IN , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgradex Abandon( ) an individual, sewage disposal system
at
Disposal System Construction Permit No./ `� �- , dated
as described in. the. application for
Provided: Construction shall be completed within three years of the date 'of th15brtit. All local cogAitions must be met.
Form 1255 Rev. 5196 A.M. Sulkin co. ChMestown, MA Date ^ Board of Health // �` �� �� Zl