HomeMy WebLinkAboutApp-Permit-ComplianceNo. B0 NDC-( 8 --trim ,C L T FEE
COMMONWFALTH Of MASSACHUSETTS
Board of Health,
MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION P I�,
Application for a Permit to Construct( ) Repair( ) Upgradei,�-<bandonO - omplete System
Location S�7
Y�� y3f'
Owner's Name &C1 jt j(4 1tr
i1r
Map/Parcel#
`-
Address OL9r��
nn G—^,r v
g
Lot#
Telephone# -)'71, 3 6, OI S
Installer's Name
Y �� /�f C��SV-
Designer's Name
Address
Address y o � no*
/'-
s� _
Telephone#
�'p - �(oaZ lOeZ3
-7-7-S-7700
Telephone# S D
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) 330 gpd Calculated design flow Design flow provided .36 ' gpd
Plan Date L' 3 Number of sheets Revision Date y 116 //e�—
Title
Description of Soil(,) S`Pif S01 ( CTS,
Soil Evaluator Form No. Name of.Soil'Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S -e -( 1J L
The undersigned aKtpt;1-a
' tall the ove d cribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t the o e a Certificate of Compliance has been i sued by the Board of Health.
Signed y Date
Inspections
No. COMMONWEALTH OF MASSACHUSETTS �t ����� / W11E
Board of Health, mA.
CERTIFICATE Of COMPLIANCE
Description of Work:. ❑ Individual Component(s)-S�mplete System
The undersigned hereby certify that the Sewage Disposal_ System; Constructed ( ), Repaired ( ), Upgraded,,,(,.4- bandoned
by
at x'101 � of j jj
1 �
has been installed i> accordance with the provision_ s 0 10 CMR 15.00 (Title 5) and thief approved design plans/as-built plans relating to
application No. / I-_ , dated 4-- ) S'• / . Approved Design Flow,��3-(gpd)
Installer - i ti 3' c G 1 rq � c G, S j,
ff
Designer:.` ^ : t ;1 ; . �i Gl k f 4� Inspector: ZZX&Date: 5 --41
The issuance of this permit; shall not be construed as a guaW ee that the system will function as designed.
1
No. iy ,-! .. �' ,,. ,„ t S _ FEE , .r �✓
COMMONWEALTH Of MASSACHUSETTS
Board of HealtlL, )�? Q 1Jin+ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade4—j--A15andon ( ) an individual sewage disposal system
at ° 'l f 1 C C 1 L"`; ��„¢ ) �. i y�'fj as described in. the application for
Disposal System Construction Permit No. dated 2 -4-
Provided:
Provided: Construction shall be completed within,"r of the date of this permi 1 local conditions must be met.
Form 1255 Rev. 5/96 A.M. sulkin Co. Chaftstown, MA Dat
Board of Health