HomeMy WebLinkAboutApp-Permit-ComplianceNo. &)km L'-- Va-61-114
COMMONWEALTH 4
Board of Health,
APPLICATION FOR DISPOSAL
Application for a Permit to Construct( ):Repair( ,) Upgrade(,4"Abandon,O - ❑ Complete System
—6011,E 0
Location
Owner's Name
Map/Parcel# �'�j
Address �� _ �, rvvv T
Lot# \
Telephone# : �CA
Installer's Name ,�Z.--
- " —
Designer's„Nam!,�
Address
c�
Address
k
Telephone# 5e=i—
Telephone# rem , 3
Type of Building - Lot Size' e Y 'lam fvc aT.. V-
Dwelling-No.'ofBedrooms !7 Garbage grinder( )
Other - Tv
pe of Building No. of persons Showers ( ),Cafeteria< ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided _Z1Y Q— gpd
Plan Date_ �5' Number of sheets oS Revision Date
Title
Description of Soils) IJD�
Soil Evaluator Form No. Name of Soil Evaluator t). Date of Evaluation
DESCRIPTION OF REPAIRS OR
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 syste • operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Datec��
Jr, Inspections
c
No. r � � ( - c) COMMONWEALTH OF MASSACHUSETTS FEE
330L4
Board of Health, di -
CERTIFICATE OF COMPLIANCE bw jA`t
Description of Work: 0IKi vidual Component(s) ❑ Complete System 01 �V
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded (Abandoned ( )
y:
at
has been installed i accord nce with €the 1provisions of W CMR 15.00 (Title 5) and th approved design plans/as-built plans relating to
application No. dated ql r'y K Approved Design Flow (gpd)
Installer L
Designer: 4'Y = ter-._ Inspector: � ¢� Date: I
The issuance of this permit shall not be construed as a,guarantee that the system will function as designed,
No. ix t) - -, ! C _' i} ` _ �� �' t� 1 FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y&UMU fR , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to, Construct( ) Repair( ) Upgrade ( vy Abandon ( ) an individual sewage disposal system
at �- �- nib as described in. the application for
Disposal System Construction Permit No. X �-� , dated
Provided: Construction shall be completed within three years of the date of this ri 't. All local cond' ions must be met.
Form 1255 Rev. 519E A.M. Sulkin Co. Cha�eslown, MA Date Board of Health G'