HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60VVDC-1LYnO C � / 17 �(.' FEE �Uv
COMMONWEALTH LTH ®f MASSAC14USETTS citt-
v Board of Health,ia iii®lirMA.
APPLICATION FOR DISPOSAL SYSTEM[ CSN TRUCTION PERMIT
. Application for a Permit to Construct(U( epair( ) Upgrade( ) Abandon - Complete System ❑ Individual Components
Location 3 9
Owner's Name
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Map/Parcel#
7�_
Address
Lot#
Telephone#
Installer's Name
' U f
1 Designer's Name
O �, r
Address/ I'j
15 _
i Address
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Telephone# W
a 6
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3gpd Calculated design flow Design flow provided 3 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) f 497a-,4
Soil Evaluator Form No. Name of Soil Evaluator / ♦ eg a %! ' (rni t +Date of Evaluation S
/l 1
DESCRIPTION OF REPAIRS OR ALTERATIONS ®'��' G
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pla the system ip operation until a Certificate of Compliance has been issued by the Board of Health.
Signed' `ZV ,1 �`�� / ' Date Z 3: -
Inspections
No. 6 0ski 1;i . I "' % FEE SS,.. G Q
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, MA. tit f it
CERTIEI ATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify ttthe Sewage Disposal System; Consuucted ( ),Repaired ( ), Upgraded)jtiAbandoned ( )
by:1
at 2
has been installed in • ccordance with the ro,11TO of�' CMR 15.00 (Title 5) and th roved design plans/as-built plans relating to
application No. i� /�� ! , dated y- !r"? Approved Design Flow (gpd)
Installer f -1 +_,rt" /?11 sir' 7 a -%. 11 Ir f I
Designer: Dx.;, %r..t L A"�I "` Inspector: �%� ' 7 Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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- -- No. U1 i R'" y,' 4E; FEE 00
1"-1011-7 COMMONWEALTH Of MASSACHUSETTS
Board of Health,MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to,; Construct( �,)/ Repair( ), Upgrade Abandon( ) an individual sewage disposal system
at
n
as described in the application for
Disposal System Construction Permit No. t�� '✓"�w /, dated
Provided: Construction shall be completed within aug f tfie date of this permit. All local conditions must be met.
... .,? r r It •J! � '.� � ice„
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestsr, MA Date / r`� Board of Health
i.