HomeMy WebLinkAboutApp-Permit-ComplianceFEE' V 5
COMMONWEALTH Of MASSACHUSETTS d4 *1b
said of flealth, )6V- VT74- MA.
/O AlPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION SPERM T
Application for a Permit to Construct( ) Repair(_) Upgrade AbandonO - Q -Complete System ❑ Individual omponefits' t
LocationOwner's
Name ✓
Map/Parcel#
Address _ ,,,,C!
Lot#
Telephone#
Installer's Nam
Designer's Name
AddressSZ-d�0:
�� t y T
Address 15 --j
Telephone#
Telephone#
Type of Building ALd�4*rR)
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Size
Lot
sq. ft.
Garbage grinder ( )
Showers ( ),Cafeteria
Other Fixtures
Design Flow (nu required) �y gpd Calculated design flow_ Design flow provided 5-5-''L gpd
Plan: Date l `� 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
i
The undersigned a es o all the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 -and
further afire o t pla the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date l�
`Inspections % / i %�`"s �°��-- 7 "1'x' 4W a2W �f 1� Pik' ey --
No. 1606��%�`~!�'I�ircJ 7 X7! FE)
COMMONWEALTH OF _r
Board of Health, Yaf&6014
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) �mplete System
The undersigned hereby certify that the Sewage Disposal System; Constr cted O, Repaired (w-), Upgraded ( ), Abandoned ( )
by:
at �i r� 14te ke4 f-,fi/�u
has been installed in accordance with the provisions o 310 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No. ,may dated /Approved Design Flow pd)
Installer C Ql�ll��- L�(JS*l�tic� /- G/iJ P, Srm�./+MP�1�
Designer: ECer %G/� Inspector:� �f (s l��j Date: +fit 1Y°
The issuance of. this permit shall not be construed as a guarlintee that the system will function as designed. --`
No. • 14� am7 � `OA L �.-i� i , FEE . O®
19-11
COMMONWEALTHMASSACHUSETTSchi i
Board of Health, Y ()0 , Am.
DISPOSAL SYSTEM[ CONSTRUCTI®N_ PERMIT
Permission is.herebygranted to; Construct( ) Repair(kl Upgrade( ) Abandon( ) an individual, sewage disposal system
at ��i S C' //-PXL�Cti'll�� ,�CartrZ.. as described z the application for
Disposal System Construction Permit No. e `�A , dated / y .
Provided: Construction shall be completed within of the date of this permit. All local condi 'ons must be met.
r?r J�
Form 1255 Rev. 5/96 A.M. Sulk' n Co: ChaBeSlo n, MA _ Date % Board of Health