HomeMy WebLinkAboutApp-Permit-ComplianceNo. O c-t - 6 �,& re� Ic /-(/v FEE'
COMMONWEALTH OF MASSAC USETTS
Board of Health, _VARM QTA „ MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application for a Permit to Construct(,) RepairyUpgrade( ) Abandon( ❑ Complete System 9 idiyidual Components
Location
Owner's Name
_ tr
Map/Parcel# Q 17 , I `T 1, C 1 _
Address 60,)-
c-MI)VI 1 L. (�
Lot#
^
Telephone# W �'' 6
Installer's Name J C-9-
Designer's Name
Address
LorS
Address
Telephone# __
Telephone#
Type of Building U4`Lot Size sq. ft.
Dwelling - No. of Bedrooms W Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator FoLui Na. Name of Soil Evaluator Date of Evaluation
WESCRIPTION OF REPAIRS OR ALTERATIONSVA` SC(� �Jf
� I -C
f:la .d1L, E
bed Individual Sewage
Son until a Certificate
Date
Inspections
System in accordance with the provisions of TITLE
aai� ce has been issued by the Board of Health.
o .�
o`
' �� COMMONWEALTH ,� LTH OF MASSAC�SETTS %yam 77, `�
1A ] i `" IC
Board of Health, - V .6xT * , MA. v
CERTIFICATE Of COMPLIANCE
Description of Work: dividual Component(s) ❑ Complete System f
The unders ed he, ebyc rtify that the Sewage Disppsal System; Constructed ( ), Rep i ,e Upgriaded ( )> Abandoned ( }
has been installed in a orlon with the prodisi s�of CMR 15.00 (Title 5) and the approved design pla, as -built plans relating to
application No. �� ` dated' 1 yip Approved Design Flow "-` (gpd) I
Installer �J C F F t { ��t - L"- E ic''VT NJ
Designer: Insp
The issuance o; hispermit shall not be construed as
No. �71NJTK-
Date:.
ee that t e°sysiem will function as design{ d.
COMMONWPjk1T4f Of MASSAC USETTS �6LY
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair{ Upgrade( ) Abandon( ) an individual sewage disposal system
at �: (\R-:7 / as described in the application for
Disposal System Construction Permit No. C, dated Q ems•
Provided: Construction shall be completed within three Yeats of the date of this perm i local condition must be met.
Form 1255Rev. 5/96A.M.SulkinGo. ChaBesown,MA Date: QBoardofHealth �.