HomeMy WebLinkAboutApp-Permit-ComplianceNo. � /."`i'C) 69 TR
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COMIMION TSI Of M ASSAC14USETTS ��u�,.awj I
Board of Health, rn Y CAL-P1hJUN ' , 24 209
11 46 ROUTE 28
APPLICATION FOP, DISPOW*V9 +WWMJCTIONRU.TH DV
Application for a Permit to Construct( ) Repair04 Upgrade( ) Abandon( - omplete System ❑ Individual Components
Location
n% C,
Owner's Name
C
Map/Parcel# o
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Address )
D
Lot# b
Telephone#
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Installer's Name e µ
O N /Z C
Designer's Name
Address .0, AIDX S
/ilIg 2STD S
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Address
n1�
Telephone# 5--
O - VW
ITelephone# -
9•13 11'1 l Lam'
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Size
Lot
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. r quire) gpd Calculated design flow 7 Design flow provided gpd
Plan: Date .5 Number of sheets Revision Date
Title
Description of S`oil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The unde 'geed agrees install a (bove d cribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furl agrees to no the m operation until a Certificate of Compliance has been issued by the Board of Health.
Sign d Date cat"
Inspections
No. T (%' FEE
COM[MIONW LTII OF M ASSAC14USLTTS
Board of Health, f1) , MA. c 4- clsz
CERTIFIC T OL COMPLIANCE
Description of Work: ❑ Individual Component(s) omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( , pgraded ( ), Abandoned ( )
% _ �- �'
at I --,- —T i
has been installed in accordance witfithe provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated - - . Approved Design Flow (gpd)
Installer
' ` ri or• � ✓: � � V, i . Date: - 5 ._ -� _ t
The issuance of this permit shall not be construed as a g aranteesthat the system will function as designed: -
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
FEE
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Permission is hereby granted to; Construct( ) Repair( ,.)' Upgrade ( ) Abandon( ) an indi� idual sewage disposal system
at as described in the application for
Dispo§al System Construction Permit No. j. dated
Provided: Construction shall be completed within three _ th date of this perm/it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charles own, MA Date -- , / �oard of Health -' / f_ :' ` / f