HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1uClP7'LJe ^ S2 -S-7-7 /! eel .' _/ � FEE 00
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COMMONWEALTH OF MASSACHUSETTS �o�oss2y
_ - Board of Health, OT4f , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) 6j Complete System ❑ Individual Components
Location AV(?-
Owner's Name
Map/Parcel# qci1
Address \ e
Lot#
Telephone#
Installer's Name }
Designer's Name •
Address _$_ r Mc,
Address Ci ;� t
Telephone# 50% -Liz-Z_
Telephone# a - (o'2--14CD,4 I
Type of Building Q,Q MMeXC \ QA 25u, \ 6yI)s 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) gpd Calculated design flow Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Description of Sbil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Ind' 'dual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation a Certificate of Compliance has been issued by the Board of Health.
Signed • a • Date - Q3
- .Inspections
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No. Li0 1 C EE Pc.a
COMMONWEALTH OF I ASSACHUSETT � T .. co 6032.4
Board of Health, b7 QMA , MA. t ' p,�Af , 7
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) -•l omplete System �( ' 1
The undersigned hereby certify that the SewageDisposal System; Constructed ( ), Repaired Upgraded ( ),,Abandoned ( )
by: � f .k .c f'- � - - , G (` `d, •• "`.%
at
has been installed in ac or ance with the rovisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. dated C Approved Design Flow` * (gpd)
Installer , 6
Designer.: Inspector: i ' i'' Date:
The issuance of this permit shall not be construed as a guaree that the system will function as designed. '
No. G 7 b , 0 0 ` Cc) y - FEE 00
COMMONWEALTH OF MASSACHUSETTS 00992.-q
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(,'` Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No..42L'� , dated -_,,V
as described in the application for.
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Datel rjv Board of Health
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