HomeMy WebLinkAboutApp-Permit-ComplianceNo. �D�-l8-03 1 �LJm' 19- a ® 2-55-� FEEY.' 00
/,COMMONWEALTH Of MASSACHUSETTS
Boa)d ofFleulth, YA&mTn7+ MA.
`
APPLICATION TION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
pp ication for Pd'rmit to Construct(' ) Repair( ) Upgrade( ) Abandon( - Z Complete System ❑ Individual Components
Location -`-3 A,,Vi
Owner's Name �¢ p�y(J
UJ
Map/Parcel#
(i
Address Z -3J Y`ry� -0
Lot#
Telephone#
Installer's Nam e/
� � ire
crr, cSZ
Designer's Name �(�1`°1►�.
Address L3C L
Address VS173 V'' -W, J
'PIA
t7 /�
Awils
Telephone#
Telephone*
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder {) w6
Other - Tvpe of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) 4 3 gpd Calculated design flow 3✓t` Design flow provided 5 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils) _
Soil Evaluator Form No.
DESCRIPTION OF
OR
Name of Soil Evaluator
c-ov els�
Date of Evaluation
jpd6
The undersigned agrees to ` tall the above described Individual Sewage` Disposal System in accordance with the, provisions of TITLE 5 and
further a to of to pla the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
No. t�"�j . .EEE 00
COMMONWEALTH. OF M, ASS CHUSETTS `
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 1] Individual Component(s)' M'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade, Abandoned ( )`
at -� --Z, ,,,vtluV t . , A,l o cr
has been installed in actor ce with the provisions of14 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow _(gpd).
InstallerC-� �j�ccsc�Jr�.--v`c.c- / �Tl,(.��
Designer: Inspector: !' Date:... _
The issuance of this permit shall not be construed as a gu rantee that the system will function as designed.
a No. n,° v r l .
FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �-�/i ()li�- , MA.
DISPOSAL SYSTEM CONSTRUCTION. PERMIT
Permission ishereby granted to; Construct(ZRepair( ) Upgrad Patidon( ) an individual sewage disposal system
C+ 12-� p, IOU �at
Ir
Uj � ( 0 (A
at as described in the application for
Disposal System Construction Permit No. / ri .-�J ib , dated
Provided: Construction shall be completed within three years of the date of this Litt. All local con tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chaftstow�n Date ! Board of HealthC{-
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