HomeMy WebLinkAboutApp-Permit-ComplianceNo. �O ►7�C-llj�O�/� 1�
f 5 COMMONWEALTH OF MASSACHUSETTS
Board of Health, V P a M , MA.
FEE'
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Bandon( ) - ❑ Complete System VIudividual Components
Location
'3r p/y �(
Owner's Name
Map/Parcel# 22 3 C ! Z
Address Gn O ro -P,�J !a.
Lot#
Telephone#
Installer's Name G
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Designer's Name
Address
j Co .-ti..•,G L; ✓� 1 �✓'(
Address
Telephone#
y 'j $ —j ')
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
nrher Fixnn•es
Design Flow (min. required) gpd 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.Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS "��t0-� . �Z-� " _-ap z
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �� C �- Date
Inspections
No. o C—Ie--- 0 2_ 7 �°` �� FEE
:.- COMMONWEALTH I.TH Of MASSACHUSETTS
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ;(A, Upgraded ( ), Abandoned ( )
athas been installed in accordance with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. '=%.� • datedl .�!*% Approved Design Flow (gpd)
Installer- c k = J C-e``A
Designer: --- - Inspector: 1..1C Date: /,(l
The issuance of this permit shall not be construed as a guarantee that the lystim will function as designed.
No. 1(30 v`13,, �lJr2— 7 l ti
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �/ ,fit r� qv�A-- , Am.
FEE ^� X
C�...- 13
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is.hereby granted to; Construct( ) Repair(j Upgrade ( ) Abandon ( ) an individual, sewage disposal system
at
Di
as described in. the application for
Provided: Construction shall be complexed within three years of the date of this p ri ' All local,fo tions must be met.
Form 1255 Rev. 6/96 A.M. Sulkin Co. Chadesiown, MA Date / '-/ Qoard of Health.