HomeMy WebLinkAboutApp-Permit-Compliancec No. W-DC -48-0 ` Y l -& L11_1_f2_'V9 OO 1 Sv lO FEE'd sr-�r 0D
_ COMMONWEALTH Of N1 ASSAC USETTS
r! � Board of Health, MO TII MA.
LI TION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( ) - 0 Complete System 915d_ividual Components
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Location
Owner's Name Q
Map/Parcel#
Address
r
Lot#J�
Telephone# 5 D 8 -
Installer's Name
Designer's Name
Address
_
ddress 12,
Telephone# _ - 1'll
Telephon # l5O . Gi O
Type of Building �. F /N �Cv '� �� Ih�'��� Lot Size VR �'�_ sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers( ),Cafeteria( )
Other Fixtures qq
Design Flow (main. required) i Q gpd Calculated design flow Design flow provided gpd
Plan: Date nC - -A -7 Number of sheets Revision Date R
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Eval
—�,�s 'RN G 2.
DESCRIPTION OF REPAIRS
late of Evaluation
The under'ir' deks to install the a e s 'bed Individual Sewage Disposal System in accordance with the provisions of TITLE 5-and
further a es of i c the sy m m ration until a Certificate of Compliances has been issued by the Board of Health.
Signed Date
No.���� ! 10 FEE 45C5-06
„��' COMMONWEALT14 Off' MASSACHUSETTS
Board of Health, % '%')��� , AL4 O K ►'(Z77/V$
CERTI
Description of Work: ❑ Individual Component, TIoATE
mplete System �✓ d�'�
p ,
The un emit ned hnbycertify that'the Sewage ^Disposal System; Constructed ( ), Repaired ( ),Upgraded gQ,Abandoned ( )
by: a
at
has been installed }h ii acc r�e with the provisions of 310 CM 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 1p' �� dated � (O12L Approved Design Flow ' _(gpd)
Installer 1 V
Designer: Y' EM � Inspector: Date:
The issuance of this permit shall not be cons ued as a guarantee that de system will function as designed.
i
No.�%�% + "�� i i FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, V�2M 0 (n , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. ''x ' t '''dated i1 ,2
t,�,�,�� r ,
�J Provided: Construction shall be completed within tl:�'s:df t�e date of this pea 't. All local c • nditions must be met.
Form 1255 Rev.5/96 A.M. Sulkin Go. Challeslown,MA Date,M -.,) _.%•O Board of Health