HomeMy WebLinkAboutApp-Permit-ComplianceNo. �q 02,12�1
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COMMONWEALTH Of MASSACHUSETTS
FEE $ 6iOD
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Board of Health, & I MA.- _ _
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERIfyv A
DEC 13 2818
Application fora Permit to Construct( ) Repair( Upgrade( ) Abandon( - ❑ Complete System, I dividi Lal Components
Location
COMMS b AL4u45* S: *-/,
Owner's Name s'i6 a
Map/Parcel#
19
Address tw 13 €L &;T
Lot#
`715
Telephone#
Installer's Name C +JD
L30 Designer's Name N
Address�i
i Address
Telephone#
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Telephone#
Type of Building Rjr-s i piq m A4, 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) gpd Calculated design flow Design flow provided 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 =AJ5_ !q_ A Ji52&j 14 -1® n -ROK wl'ril RL Sia,
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 t ace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
' i t i
FEE
COMMONWEALTH OF MASSACHUSETTS 6�-
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Board of Healtli, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 91ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired Graded ( ), Abandoned ( }
has been installed ii ccor a e with the provisions of 3;0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated 0 /7f /•Approued Design Flow -" (gpd) ¢ y .r
Installer _11 R1.r.J4"h (2441rnK&
Designer: 1A Inspector: f z ipe Date: /4 f r
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No. 2 o- C A 173 -�Uz, ✓ FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, VtD , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) RepairX) Upgrade( ) Abandon( ) an individual sewage disposal system
at , o as described in the application for
Disposal System Construction Permit No. '' , dated 11 l
Provided: Construction shall be completed within tlsears of t�dafe of this permit. All local conditio must be met.
Form 1255 Rev. 5196 A.M.,Sulkin Co: Cha iestown, MA Date/)--/-"
oard of health '✓ Com'