HomeMy WebLinkAboutApp-Permit-ComplianceNo. -on C_'LC.�
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S-2 COMMONWEALTH Of MASSACHUSETTS
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Board o Health, T��U (�i�r , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
App ication for a Permit to Construct( ) Repair( ) Upgrade( AbandonO - ❑ Complete System aIndividual Components
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Owner's Name a
ap/Parcel#
Address YI tAc.Q�J
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Telephone#
I astailer's Name
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Designer's Name 306w(W Erwyleb-i
ddress D
Address (.�3C1 IvlW-K ' AY O
Telephone# Z
Telephone# .
Type of Building 1 Lot Size sq. ft.
Dwelling - No. of Bedrooms V Garbage grinder(
Other - Type of Building No. of persons Showers( ),Cafeteria( )
Other Fixtures ��tt,
Design Flow (min. required) V gpd Calculated design flow Design flow provided �33 6 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr to not t lace the system in operation until a Certificate of orn idnce has been issued by the Board of Health.
Signed Date
Inspections [ _4 ' e� // 5
4—
f COMMONWEALTH OF MASSAtCHUSETTS t�
Board of Health, V r � (i t 1 , MA.
CERTIFICATE
7"V'f COMPLIANCE
Description of Work: -< ndividual Component(s) ❑ Complete System
The undersigned hereb�ncertify that the Sewage Disposal System; Constructed ( ), Repaired ( )Upgrade ),Abandoned( )
by: � ,{ t ((� t L. ., 3 i I i t �� (1.-L L
has been installed in accordance with the provisions of,310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated /� i{ _ rV . Approved Design Flow:3 (gpd).
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I
Installer t ` � l otit ( % U �� � Lit
Designer: V# jA r Inspector: ,/ Li f l i Date: r
The issuance of this permit shall not be construe as a guarantee that the system will function as designed.
No.
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, TY' Q J-1-A MA.
DISPOSAL. SYSTEM CONSTRUCTION' PERMIT ;..
Permission is hereby granted to;, Construct( ) Repair( ) Upgrade Abandon ( ) an individual, sewage disposal system
at i>1 tl i, GI I A �d(., i (.\.� as describes in. the application for
Disposal System Construction Permit No. ated
Provided: Construction shall be completed within it ohs date of this permit. l,local conditions rust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 140 C- - /IPBoard of Health