HomeMy WebLinkAboutApp-Permit-Compliance9V 77-17
FEE' P10-00
I7- -COMMONWEALTH OF MASSAC14USETTS J2440-76
%l --'Boar d of Health, %07 , MA.
APPLICATION FOP, DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construc Repair( ) Upgrade( ) Abandon( ) - �mplete System O Individual Components
Location
Owner's Name -r—
Map/Parcel#
Address
Lot# _ '3LfTelephone#
`
Installer's Name- not cam CIL 41 V1
Designer's Name S e
Address �- o v
°,, t-
Address
Telephone# cr
Telephone# V R-- 7 ZE
Type of Building Lot Size sq. ft.
Dwelling- No. of Bedrooms _ f Garbage grinder ( )
Other Type of Building No. of persons Showers ( ), Cafeteria { )
Other Fixtures
Design Flow (min. required) qqogpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of SoilEvaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ��^U D ag I_TA n K g 0 D alL I
The undersi afire o ' tall the above described Individual' Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further afire not Ice the system in operation until a Certificate of ompli ice has been issued by the Board of Health..
Signed Date
Inspections
I -ice �% . �w�s�f /�� ./ ' 1L,0 yRC/Jr ld ,t rulm f
No. t`}M !�"�.��L FEE1 a
COQ' MONWE LTH Off' MASSACHUSETTS o � � -���/�q0-76
Board of Health, YagA®i� MA. ,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) _,�' Complete System
The undsigned hereby certifyat the Sewage Disposal System; Constructed r1l> Repaired ( ), Upgraded ( ), Abandoned ( )
atv' z 44
e P rfl+�t1(�
has been installed in accordance with the provisions of 310 R 15.00 (Title 5) and the pproved design plans/as-built plans relating to
application No. ,�`7 %/ dated �"'� � % % Approved Design Flows�•�(gpd)
Installer 11 1 U -- - -- ,,/,t U-� I i ,n
Designer: �� c^. • Y -G C) Inspector: % Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
-- -- No.
/ 7 - � 7 COMMONWEALTH Of MASSACHUSETTS
Board of Health, T7 Yrftm mT , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby ranted to; Construct (i'r Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at Dt <- i
. 6 cv -$ ✓ �v/a i riovP as described in. the application for
Disposal System Construction Permit No. !' % ? , dated 0 - d - /.7
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 ev. 5196 y.M. Sulki Co. h destown, MA Date00' / -f oard of Health t
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