HomeMy WebLinkAboutApp-Permit-ComplianceNo.
_ 10�_ 004�gv � ;
COMMONWEALTH Of MASSACHUSETTS
Board of Health, I LTTH , MA.
FEE
CJS 1I�7
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( -Ja Complete System ❑ Individual Components
Location z,fo m c /� ��
Owner's Name }mak-, i i ara
Map/Parcel# y'9. I5b
Address S3 4; ckaod-5cm �Qd f -8efniok MA 0
Lot#
Telephone# 61, " q6 -1-,31-71p
-31'T(p
Installer's Nameharsp' e( -&Ka k
Designer's Nam t5kr C AA `nom n
Address P - , D augim izcI r-
Address aD3 5efL4CL& 1 fMox '71 '5
Telephone# 3-0 . Ito
Telephone# S O ..0 e> _ 00
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms V 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
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further aQAees to no to plac, hee system operation until a Certificate o Corp�li,�aoce has been issued by the Board of Health.
Signed L 1/l� Date i j ►_►_"(�
Inspections
4-19
No. i'`;? i 3 (A- % '1 i - FEE U .
COMMONWEALTH OF MASS . CIIIIJSETTS 7
Board of Health, YA12 0 UT , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ®-mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by: j1r'j
at q i'k G
has been installed in ac o ance with the provisi ns of 3 0 CMR 15.00 (Title 5) and the approved design plans/as built plans relating to
application No./�', dated Approved besign Flow' (gpd)
fi
Installer f �y %1_ i1 i V) Pf ( 11 It. iAt 1- -T a 4-t- M 2 f 9&It
The issuance of this permit s1 all not be:coAstrued as a,guar9fee that the system will function as designed.
,
No.Qui GC--3f� �SJ .�j FEE , 00
COMMONWEALTH Of MASSACHUSETTS C�A- (195—,7
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION. HERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(\ Abandon( )an individual; sewage disposal system
atas described in. the application for
Disposal System Construction Permit No.° ": dated.
Provided: Construction shall be completed within.44r,rs 0 date of this per K
init _ All locale , d dons must be met.
/�j,
Form 1255 Rev. 5/96 A,M.SulkinCo. Chailestown,MA Date r(! Board of Health �Jt if