HomeMy WebLinkAboutApp-Permit-Compliancep 70161
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Q COMMONWEALTH Of MASSAC14USETTS (600LU C6
Board of Health, )�A•ajmDxYiu „ MA. . V'
MIX-
APPLICATI®N FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
lication for Permit to Construct Repair ` " rade Abandon ❑ Complete System ldindividual Com onents
P� O 'p (�J' UPg O O- p ys p
Location (`
Owner's Name
Map/Parcel#
t C'iZ
Address I _ \ tf Y�nrib
Lot#
Telephone#
Installer's Name �� �L (- Co T f
Designer's Name U.)\(,) t ee(t
Address '
QAA-tdressCj
Telephone# - y Z- Qe
Telephone#'
Type of Building t ()\eV^l�- 0-1 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) C 33 0 gpd Calculated design flow 326 Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of.Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to
further agrees t to L
Signed
Date of Evaluation
tie described Individual Sewage' Disposal System in accordance with the provisions of T= 5 and
in operation until a Certificate of Compliance has been issued by the Board of Health.
Date 4 jq-6
No. "V &•- � 7 I s 'c (' Xlj % FEE pI — — 00
COMMONWEALT14 Of MASSACHUSETTS-,)fir;
r Board of Health,
CERTIFICATE OF COMPLIANCE f _ 64
f
Description of Work:; dividual Component(s) ` O'Complete Systems}j�'
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded Abandoned(
by: t�[ a ?�� Doe
C7C3 . It-3
at
has been installed it accordance with the revisions of 310 CMR 15.00 (Title 5) and th5(gpd)
roved design plans/as-built plans relating to
application No.,y' � + dated I . Approved Design Flow
Installer -0 T
Designer:1f ,.,-) l CA, (- C—'}w3(' ! M i Inspector: s' Date: r t
The issuance of this permit shall not be construed as a,guar,8� that the system will function as, designed.
No. % 1)% l) , W C` FEE €�%
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COMMON��,TH Off' MASSACHUSETTS
Board of Health, ��rz f� �-r Am.
DISPOSAL S1TSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;, Construct( ) Repair( ) Upgrade'(,. Abandon ( ) an individual sewage disposal system
at k t AM t fe-Pr r4A.) , (�t as described in the application for
Disposal System Construction Permit No. � dated '�'... j
am,
Provided: Construction shall be completed within-dVA"�gcars orw��e date of this permit. ` local conditions Dust be met.
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Wm-1255 Rev. 5/96 A.M. Sulkin Co. ChaileStown, MA D'dte .E / Board of Health `' y fy'
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