HomeMy WebLinkAboutApp-Permit-Compliance"2,
No. �'1 ?-V� 4 FEE a;60
COMMONWEALTH OF MASSACHUSETTS
and of Health, MA.
� lL
CMIV FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) 0 Complete System O Individual Components
Location j,Aj f �Itj
Owner's Name
Map/Parcel# Z
Address
Lot#
Telephone#
Installer's Nam b611Sr
1.41
Designer's Nam g
Address K U:
Address
Telephone#� _ f 2
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 _
Design. Flow (min, required) �2b gpd Calculated design flow �� Design flow provided ZZ Z-- gpd
Plan: Date f,/—// �� Number of sheets / Revision Date i
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS�6 e2 ,e ie—LA?AA, 5-7- l i C- SV X7- M,
The undersigned a ees to inst the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5,and
further agre�to t to pl ire system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed , Date Y __
Inspections C)1 A N�I� "` %� U l.�l � !d'� CCS/ "�-
/e ��� i7 V 1>-1wow/� e . i� hAy TA�
/ �,- .) /a
v'
'! EE ,
COMMONWEALTH OF ��AUS�ETTS I q P 6
.ell
Board of Health,VA1.EnA MA.
CERTIFICATE,� OF COMPLIANCE
Description of Work: El Individual Component(s) 0 omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded (01/,Abandoned
( )
by: nz&m-C-1;6"U
at 1rs OPAL--- C .w 1,4 4c)has been installed in accord with the rovisions of 310 CMR 15.00 (Title 5) and th�aproved design plans/as.-built plans relating to
application No. � dayd %/ .Approved Design Flow . _ /_
a
Installer I -A-4-04C d- / s -f r *sem r err
Designer j .,;n s Inspector: 'f Date: f
The issuance of this permit shall not be construed as a gua ntee at the system will function as designed.
No. �jC i �. 1 E to ? f rt•£/�jd C� ji}f- -<- — _ _. - - - FEE,,'
COMMONWEALT14 OF MASSACHUSETTS ('o,
Board of Health, _ -1Ao- MO 11774 km..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct('t' Repair( ) Upgrade (Abandon( ) an individual sewage disposal system
at'gt ) as described in the application for
Disposal System Construction Permit No. , dated f Q
Provided: Construction shall be completed within three years of the date of this perrm, Al peal condign, s�must be met.
Form 1255 Rev: 5/96 A,M. Sulkin Co. Cha leSlown, MA Date/` r?c ayrd of Haltth