HomeMy WebLinkAboutApp-Permit-ComplianceNo. gonC���ZZZ
s 1k,
[3LDTR-I.3-s00193e
EC N0A"�' TTSNW Board of Health, 1 Q-Q1R MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair( ,) Upgrade,(Ij Abandon.( LeComplete,System O Individual Components
i
Location
Owner's Name
Map/Parcel# eizoAddress
ut�
Lot# ;2;2 o?
Telephone#
Installer's Name hejn5 '-
Designer'sName
v
Address �J0. / f.
Address P
Telephone# _
Telephone#
Type of Building
Dwelling - No. of
Other -Type of Building No. of persons
P sq. ft.
arbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) _2?� gpd Calculated design flow �� Design flow provided_ gpd
Plan: Date �..T. 2l�/ _ Nurnber 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 ®D
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 system in operation until a7�ate
ate of Compliahce has been issued by the Board of Health.
Signed
r
�S
co
COMMONALTR DOE MASSACHIJSETT
Board of Health, � MA.
CERTIFICATE OF COMPLIANCE ��41- ,_ a � l/ r8
Description of Work: O Individual Component(s) M"Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired Upgraded (andoned
at
-s
has been installed in accordance with the provision3Aof 31 CMR 15.00 (Title 5) atid the approved design plans/as-built plans relating to
application No. ✓ � .). C:;� dateO- pprovedbesign Flow-(gppd) ,
Installer jY t zr,6-v, .. 4JAA&J,s
Designer: _E+'�"�� '" f. zF Inspector: ri Date; _
The issuance of this permit shall no be constr ed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
-4-- IE
Permission is hereby granted to; .Construct( ) Repair( Upgrade XAbandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. /` �`� dated/6 -.
Provided: Construction shall be completed within t A�st5 date of this permits All local con tioiji s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin co. chadestown, MA Date( e"' /' � Board of Health J�