HomeMy WebLinkAboutApp-Permit-ComplianceNo. p NX -I —199 7f 1 FEE .. 0551.0_0
COMMONWEALTH ALTH OF MASSACHUSETTS CQ+q o%
Board of Health,<1 O V f 7 , MA.
i- PPLICATIOld FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( epaic,O Upgrade( ) Abandon( - ❑'Complete System ❑ Individual Components
Location, 5 ,� d
Gt'1C� d:
Owner's Name C C C is i Y
Map/Parcel#
Address �. �, dad
Lot# `O
Telephone# -7 7 `) - °3 G `/6
Installer's Name(,(ter 1_41,J
�� f sLE
Designer's Name
Address 170 o)r % (a
Address
Telephone# Sar,. 776- 6r
Telephone#
Type .of Buildingreg; fAcn }r %- _ 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 Soil (s).
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS .OR ALTERATIONS _ TPA��z� bOX
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, �i� �� Date G
Inspections
No. �3 (` }��'f �T. �( �(� MASSACHUSETTS
/� ( �T FEE�� Q0
CO MON LT14 ®f MASS CHUSETT�
Board of Health, A1,zM0 7W , MA.
CE TIrICATE Of COMP IANIICE,
Description. of Work: individual Component(s) ❑ Complete System
r
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ); Repaired), Upgraded ( ), Abandoned
as
has been instft-dii cc ce with the rovi ons 310 CMR 15.00 (Title 5) and the :approved design plans/as-built plans,relating to
`1 ^� Approved Design -Flow d
appl caj9p [N�, dated pp_(gpd)
Installer /' • k, - U'—' _
Designer: Inspector:% Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No., 60r 1Dc-4 ��1 FEE S
COMMONWEALT14 Of MASSACHUSETTS �
t Board of Health, 007 !T MA
DISPOSAL SYSTEM CONSTRUCTION --PERMIT
Permission is hereb .granted to Construct( ) l ..� (,) Upgrade( j Abandon( ) an individual sewage disposal system
at / d-Gr'''�� ti iJleq as described in the application for
Disposal System Construction Permit No. 1—(�t��°' ,dated
Provided: Construction shall, be completed within three: years of the. date of this permit.,
All local conditions must be met.
Form 1255 Rev. 5/96: A.M. Sulkin Co. Chadestown, MA Date ` ��f % Board of Health � //