HomeMy WebLinkAboutApp-Permit-ComplianceNo. ffO-0j)C-4" Y00 � � �TY% YG�-rW / ✓ FEE
Board of Health, Yd:P=/%i o0T , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct({( Repair( ) Upgrade( ) Abandon() - ❑ Complete Systedividual Components
Location 10
1911l
Owner's Name Xon
Map/Parcel#
O
Address /,0 �
Lot#
Telephone#
Installer's Name s
Designer's Name 6 v
Address
p ,Aki1.0.
Address PD /72
Telephone#
860 '729S-01/
I Telephone# O z ,36bb
Type of Building V /hq
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size f2, 3 #O sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow` Design flow provided gpd
Plan: Date /✓OY• 2,90 2-0 /A Number of sheets .2 Revision Date
Title -,
Description of Soil(s)
Soil Evaluator Form No,
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
P%
A ea,
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 a Certificate of Compliance has been issued by the Board of Health.
Signed Date 11 /3D118
Inspections
No. ��FEF
A' _,2 COMMONWEALTH Of SSACHUSETTS 0 1
Board of Health,
CERTIFICATE OF COMPLIANCE
Description of Work: Xhidividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed , Repaired ( ), UpgradedyAbandoned ( )
by:
at
has been installed itaccorda ce,/with the pro��si is ofj� CMR 15.00 (Title 5)
application No. !i " - dated Approved Design Flo
design plans/as-built plans relating to
Installer -4 ZWorJ-- -`#1W r'r./
Designer:EA m Inspector: Date: //
The issuance of this permit sh not be construed as a guar6fitee that the system will function as designed.
tJScL+�;} .�
'No. � 1 - 1T7 `IJ�0 � � `^--' FEE 6 Q V TCOMMONWEALTH Of MASSACHUSETTS
Board of Health, MO 1Unj > MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repairk Upgrade("' Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No.
as described in the application for
51
Provided: Construction shall be completed within three6W4-Mrs of the date of this per �tt All local conditi s must be met.
�
Fofm1255 Rev. 5/96 A.M. Sulkin Co. Chadestown. MA Date !�' ` U �t`� Board of Health