HomeMy WebLinkAboutApp-Permit-Compliance'No.�J / FEE'
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i yv Board of health, y4f2mbUT4 , MA.
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FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( )`Repair( ) Upgrade(�bandou( ) - a'Complete System ❑ Individual Components.
Location
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Owner's Name -3-0 )IJ '1,.hW
Map/Parcel#
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Address .I U llso' Q -1T
Lot#
Telephone# - '3(.0:+53 S,
Installer's Name
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Designer's Name Q()WvL-D l C_
Address fd
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ddress ,b ,80 a� 5 (t) t� p d �
Telephone#
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Telephone# r? Ct-7QO
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms �� Garbage grinder {
Other -Type of Building No. of persons Showers O , Cafeteria
Other Fixtures 0r�
Design Flow (min. required) % 0 gpd Calculated design flow Design flow provided b gpd
Plan: Date I Number of sheets Revision Date
Title
Description of Soil (s) A '� l/l " i ®A M-4 9A •� � rCl�'',,��A1 N
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Soil Evaluator Form No. Name of Soil EvaluatorA01t 1��A/ fte Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTE.RATI S fY\ q t .,j ljo-oSp✓ o m l- , ���® ` TLOO C D "N
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no ce the a in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �a� Date
Inspections
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No. 600 DC wj S-33 8i�0 FEE'
C®�'91 MONW DTII OF SSACIIIJ T 00
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Board of Tkalth, _ [.lM iilj'�� , MA.
-CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(sX +®'Complete System.
The undersigned herebyertrif_y that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded4,( Abandoned ( }
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has been installed ii accord �ce with t4 provisions 31.0 CMR 15.00 (Title 5) and e ap.
application No. / t dated fl . Approved Design Flow (g
Installer C, ..1 \ S"1') Q r (, . (J `)
design plans/as-built plans relating to
Designer: Rt t� LD CA li i SXA C... Inspector: r' Date;
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, VjAg rvt 6 >J"1 + , M.A.
DISPOSAL S YSTECONSTRUCTION PERMIT
Permission is.herebygranted to;, Construct( ) Repair( )
at
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o �o i z_
Upgrade,% Abandon ( ) an individual; sewage disposal system
!!! as described in. the. application for
Disposal System Construction Permit No.: dated- f
Provided: Construction shall be completed within rs of e date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 X.M. Sulkin Co. Cwestown,,, MA Date; 7" �� Board of Health f
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