HomeMy WebLinkAboutApp-Permit-ComplianceNo. p
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COMMONWEALTH Of MASSAC14USETTS 3377
Board of Health, yAc Mom , MA.
PPLICATION F OR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair(v, Upgrade( ) Abandon( ) ❑ Complete System Q ndividual Components
Location 11 "
Owner's Name
Map/Parcel# 3 ®
Address , -\ , e J ��
Lot#
Telephone# szt>•7 _ 3a le _ 59.-2�
Installer's Narne'R_ �� — �_,
Designer's Name
Address -tqAddress
OA
Telephone# Q - c _ �
Telephone#
Type of Building �` , Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) —
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1._�,s �a : S ��� «U✓�. Sr'T""� G �c4cly )e
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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 sptWn in operatio until a Certificate of Compliance has been issued by the Board of Health.
Date
Signed --``�
Inspections
,,No. - ` ` -4
C®Nl MONWILAILT14 OF, MASSACHUSETTS
Board of Health, ����.�T , MA.
CEDTIEICATE (V' MM I TAKE
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As
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dual Component(s) ❑ Complete System
Description of Work: WJ16vi
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The `undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired (a!Upgraded ( ),Abandoned( )
by: 3c� r— — �c L <c r ti C f �' c .. .a cT'r �° Si,
has been installed in accor nce with the p ovisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . Approved Design Flow -- (gpd)
Installer rJ - r ., E,^.
Designer: - Inspector: .~ _ Date: � /e
The issuance of this perinitshall not be construed as a guarantee that t e system will function as designed.
No. & D t—t= �1 I� - � iC .� (� 1� FEE
COMMONWEALTH Of MASSACHUSETTS �5 3-7
Board of Health, +O Lu1.iV w rrj� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) 'Repair(V,)1*'_Upgrade( ) Abandon( ) an indixddual sewage disposal system
at t ` ]::6 i a , _ ,-, <—. as described in the application for
Disposal System Construction Permit No. , dated % j
Provided: Constriction shall be completed withirWaz&v�e�arothe date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date/ Gff , / Board of Health r telll �f�t