HomeMy WebLinkAboutApp-Permit-ComplianceNo. i7�(i�C/L t/ FEE
COMMONWEALTH Of MASSACHUSETTS
USETTS
Board of flealth, �6ft 1OAMA MA.
kA
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT"
Application fora Permit to Construct( ) Repair(/)'Upgrade( ) Abandon( ) - ❑ Complete; System BIndividual Components
Location
Owner's Name 3,0 �
Map/Parcel# S �io
Address Zt..iC/`k1_->� Uf(`nn
d �^ NIC
Lot# S
Telephone#
Installer's Name sc") A
Designer's;, Name
Address
U` J /C_
Address
r 0 f3 x
Telephone# Vilf666's
1 Telephone#
Type of Building _ Lot Size / of 6 O sq. ft.
Dwelling - No. of Bedrooms Garbage grinder .W
Other - Type of Building No. of persons Showers O, Cafeteria { ).
Other Fixtures
Design Flow (min, required)(_ gpd Calculated design flow Design flow provided 3 gpd
Plan: Date Si 1 (a 1 1 Number of sheets k Revision Date
Title
Description ofSbil(s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Q _eD`C. CZ
�drrn!L_ ,�r3T� ` r x 2C.F.Aec_Pp cs, 'A .20 'DGox
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 place the system in operation until a Certificate ofCompliancehas been issued by the Board of Health.
Signed Date
op
No. bbYt DC la fFEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Vlnt , NIA.
CERTIFICATE OF COMPLIANCE
Dgscription of Work:. GYiiidividual Component(s) El Complete System.
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (✓Upgraded ( ), Abandoned ( )
by: :(TP�s - �- (6 ` �{
has been installed in ccordance with the ppro�visii . s "f 311�'CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. ' .� dated!f Approved Design Flow(gPd)
Installer nn
Designer: <4f _ s Inspector: ,r t' t..°'t�i�r' Xftt Date:
The issuance of this permit shall not be construed as a guard a that the system will function as, designed.
No. �1'? �A •i`f i. '.. I `4'5 •_ G 9 1 0 C:'['(- �ia.-p6 FEE .1t .2 t)
,&- /trt ) COMMONWEALTH OF MASSACHUSETTS i
Board of Health, 0MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is herebygranted to; Construct( ) Repair(/) Upgrade( ) Abandon( ) an individual, sewage disposal system
at ',I t A r �� C'Z t} �� P S� ��: f �.,� ��r` as described in. the application for
Disposal System Construction Permit No. -.lk, dated
Provided: Construction shall be completed within three years of the date of this rt 'e. All. local co dl ' ns must be met.
!3 _7 f
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChaBestown, MA Date r r °Board of Health �`