HomeMy WebLinkAboutApp-Permit-ComplianceNo.:-'� )%, 0®" q -a,-4 FEE
COMMONWEALTH Of MASSACHUSETTS a�838&
Yl6AMDQTV MA.
Board of Health, ,
/ LICATI®N FOR DISPOSAL'SYSTEM CONSTRUCTION PERMIT
A?
Application for a Pe mit to Construct( ) Repair( ) Upgrade( ) Abandon( -'Complete System D Individual Components
Location
Owner's Name
2x) FT
Map/Parcel#113S
Address '3pRyv�f(p
f�'J Ppjr
Lot#
Telephone#
Installer's Name &Ourc CoDesigner's
Name
Address R(259®)L l 53 2W )0
Address P.,
V 1
Telephone# S f - L.J -- ®j 3 CG
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size L �' sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. requird) L7 gpd Calculated design/flow t./ 4)e> Design flow provided gpd
Plan: Date l Number of sheets Ll Revision Date
Title
Description of Soil(s) r
Soil Evaluator Form No.
S►
Name of Soil Evaluator .e V(S >v kd 1je Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n ace�emination until a Certificate of C mpliance has been issued by the Board of health.
Signed Date
COMMONWEALTH LTH ®E M ASSAGIUSE SS r�
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
FEE
Description of Work: ❑ Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) ano the approved design plans/as-built plans relating to
application No. 4;, dated 4 _! /7. Approved Design Flow (gpd)
Installer
Designer: 1 t r _ Date:
�:f�-jam �; �-1 �1 Gam.» t�—OJ( IN �f`f2�l�r"Inspector: ,
The issuance of this permit shall not be construed as a guarVitee that the system will function as designed.
<; a^ 0 00 0 o 0 o c o c v. u a o u O c G Q. 9 00 0 Q 110 12.40.9 ago -0 O o-. C {1-1 c,. Use o_o.o 0ci-iw..2 ci�:n os>i a;.'r. y sa-c,. -,�-o aoA acu ,>�. u�•c -^ o.�* ++��a + w; N-•+-•
No. 3 ; L.� 1•i' �`�<�- � -7 �� � �� � {�L'�_ ��. ��� . f..? . � P�,} t; FEE
—, S� COMMONWEALTH Of MASSACHUSETTS
i Board of Health, - =0Un
DISE®SAI. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(q Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No.' ,,—z' dated //) -1-17
Provided: Construction shall be completed within��the date of this permit. l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA pate/19 '/;Lard of Health c)