HomeMy WebLinkAboutApp-Permit-ComplianceNo.CJ�'1a --0 GD °!�� [�_ / � Z. FEE'
2, OMMONWEA1.111 OF MASSACHUSETTS
Board of Health, �f�J'�1� , MA.
L AP LIGATION FO DISPOS L S STa CON RUCTION PERMIT
Applicatioiffor a Permit to Construct( ) Repair( .) Upgrad ) Abandon( - omplete System ❑Individual Components
Location -/-/Z
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Owner's Name /-/Zp
Map/Parcel# _-
Address -1 i j le -
Lot#
Telephone#
Installer's Name
-r's Name
Designe
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Address �z
C%�v,
Address �AS 4,?0
Telephone# �j
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Telephone# a _ Y-3 j �?
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms L Garbage grinder
Other - Ty of Building i /V �- No. of persons Showers ( ), Cafeteria ( )
Other Fixtures7y
Design Flow (min, required) r"w gpd Calculated design flow el o Design flow provided._ gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS .21710SI-411 1"4&
Date of Evaluation
The undersiI to inst the bove described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further place a tem in operation until a Certificate of ompliance has been issued by the Board of Health.
Signed Date Ol / - %
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No. .�' FEE
COMMONWEALTH OF
j s p��c ?;7Y l � T
Board of Health,(MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ..61 -Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded (j Abandoned ( )
at Z,
has been installed in accordace with the pi- isions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. -.47r, dated ✓` !3 % Approved Design Flow (gpd)
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Installer A R F . (_ k. _ .-
_:
Designer --;)11 t/ i /114 Soou Inspector: ( Date: _
The issuance of this permit shall not be construed as a guarant that the system will function as designed.
No. d..�' � �-( ti„J 'v�...��1 � �4 IC5 -- ---- --- FEE:.-��--�,-=-4�`',.; --
s _ COMMONWEALTH Of MASSACHUSETTS
Board of Health, 6 l..) -Q , MA.
DISPOSAL. SYSTEM CONSTRUCTION _ RMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon ( ) an individual; sewage disposal system
at T_ . S� (�E Y� as described in. the. application for
Disposal System Construction Permit No.: /� ` �. -7 2- , dated 73�r
Provided: Construction shall be completed within the date of this permit. All local conditions must be met.
Form 1 55 Rev. 5/96 A.M. Sulkin Co. Cheat wn, MA ,gDdtC �/. r� 1302rd Of yHealth
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