HomeMy WebLinkAboutApp-Permit-ComplianceNo. bLf 57
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YAMoonA , MA.
FEE
C.QZZD02-)
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (1!i Upgrade( ) Abandon( ) - ❑ Complete System O Individual Components.
Location zz
� a fly -
Owner's Name Go L4 l e�
Map/Parcel#
103
Address
Lot#
Telephone# �-
Installer's Name!%L�.S
o3�L�-
Designer's Name --
Address�
1261. i
Address �—
Telephone#
Z
Telephone#
Type of Building <
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION (
V� le,14
Lot Size sq. ft.
Garbage grinder (4 IZV
No. of persons Showers ( ),'Cafeteria
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Narne of Soil Evaluator Date of Evaluation
The undersigned a es t install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ofo eLth�lsy radon until a Certificate of Compliance has been issued by the Board of Health..
Signed Date
q� l r
No, tii) i 7�, c-' �`f,5-7 FEE
�.� COMMONWEALTH OF MASSAtCHUSETTS
Board of Health, A� t�1� <) i�r) , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: )d Individual Component(s) ❑ Complete System
The' undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded O, Abandoned
by: r s at
• /
...
has been installed i accordance with the provisions ojf+ R 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / �� dated �'/_�-i ^!�. Approved Design Flow (gpd)
Installer T-cm U - i_r ' e-w-( S 14
o-
Designer: ""�� Inspector` ,/ ''r tr. xa—Date:' P
The issuance of this permit; shall not be construed as a, guar4ofee that the _system will function as designed.
No. D 6' 0 DC U� () Y S� FEE: V_
r - , COMMONWEALTH Of MASSACHUS�ETTS 2z3LC)
Board of Health, YM-{i•S U U l 1A , AM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade ( ) Abandon( ) an individual sewage disposal system
at Alk l9s1 -'f �'/� -1 jL. L% -`- fi /� j i- as described in the application for
Disposal System Construction Permit No.
i . % -' dated Y Xi ,
Provided: Construction shall be completed within three years of the date of this permit.,, All local co ditions must be met..
Form 1255 Rev. 5/96' A.M. Sulkin Co. Chakstown, MA Date �� o /,r A Board of Health l