HomeMy WebLinkAboutApp-Permit-ComplianceNo. �O MV��114 �i U FEE V t/•�
COMMONWEALTH OF MASSt CHUSETTS 0ZJ011
Board of Health, 8 LrM , MA. i
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMI
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon( ) - ❑ Complete System--0Vidividual Components
Location L4s
cQ m G
Owner's Name fj
Map/Parcel#
a
Address L4 S c y,1 �ip�
Lot#
Telephone# S� 0, �r i3 6, 300'0•-
Installer's Name
'` "�s 1b wi
Designer's Name Gy i9
Address 913
Address p Q Q�-X 4�— S• �tohn'�
Telephone#
Telephone# <' o &- - $ &4 — 3
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Lot Size sq. ft.
Garbage grinder(
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) Ll -� U LILQ Calculated design flow Design flow provided ✓�
Plan: Date /9� L4,11 l ?- Number of sheets Revision Date
Title
Description of Soil(s) s 1P-C -960 J IP 4
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S WG y .0-P
The undersigned es to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees t t to cer on until a Certificate of C m 1' ce has been issued b the Board of Health.
Signed `��` Date y
Inspections_
No. Ci ! k4 �C FEE S
C
OMMONWEALTH OF MASSACHUSETTS -Z,0
Board of Health, %(Ql �_, MA. C
CERTIFICATE OF COMPLIANCE
Description of Work: ndividual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by. ! i ( Ar ; }�kp /-,), .3
at t-4 -,,� ccim-e ic+ i i Tame"/"1t L( rl 1�r9 /1-1 4
has been installecl ju accordance with the
application'No. —7, dated
Installer fOrc Cr
provisions f 1] 0 CMR 15.00 4itle 5) and the approved design plans/as-built plans relating to
9 ' 'Approved Design Flow ]Jd)
Designer;%a (-I 1 r iyG':r r') S .;,f 4"j ,-e Inspector: t /� Date:The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
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COMMONWEALTH OF MASSACHUSETTS c * -2-0 11
Board ylf Health, Y 1)11 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at (mac i r'� ' t I G='f `h ee-q -rb /9 4-,i ' as described in the application for
Disposal System Construction Permit o.1 11,6 7 , dated
Provided: Construction shall be completed withiTrthfeVMrs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Ljlyjoard of Health