HomeMy WebLinkAboutApp-Permit-ComplianceNo. CJ�G �W -1� Q�1 .' `G� r�UO� i55 VV
��"77 FEE �
lt-lw COMMONWEALTH OF MASS C14USETTS
Boar d of F3`ealth, 4dqjyr)0"4 „ MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
A plication for "a Permit to Construct( ) Repairg Upgrade( ) Abandon( ) - ❑ Complete System A(Individual Components
Location 1 P' on & , l -
Owner's Name i 5
Map/Parcel# $ 3cj/
�!
Address f6'/ypQ, AX,1 . vrlq In - `_' (�
Lot#
Telephone# 50"6-?-% -
Installer's Name :X0
Designer's Name
.Address C
Address
Telephone# 5'O$
Telephone*
Type of Building Lot d -
Size %U W3 — 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 336- gpd
Plan: Date�(31'ao10 Number of sheets Revision Date
Title
Description of Soil (s) %
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
he undersigned agrees to ' th ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t ace system in operation until a Certificate of Compliance has been issued by the Boardaf Health.
Signed Date -'
No. .1 t- Q""� ICJ FEE _ Tf . 0C)
COMMONWEALT14 OF MASSACHUSETTS iA;r�-.-
Board of Health, 1 q 3: /-T7,1, ,1, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work:. Y individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewag^re" Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by:LC ice, /+ 8 �Ii r^ E ” �✓> >P' �,_.� rr �_#�i 7 i
at I Q d0z) ('+i -Ir -1 A.1 , r )red Q11 If r't11n Alk
has been installed/i accorce with the�ro isions o10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.. ! '-" d `sell dated �a- Approved Design Flow -3 (gpd)
Installer &P 10 1 + }r !1
Designee . a . ' r��— Inspector: , Date:
L.
The issuance of this permit shall not be construed as a Wtatee that the system will function as designed.
+U;di(-; tJl !STT 9 - FEE.1d1 -
r r. COMMONWEALTH Of MASSACHUSETTS
Board of Health,Va r wit s A�4 , MA. g
DISPOSAL SYSTEM CONSTRUCTION. PERMIT
Permission is hereby granted to; Construct( ) Repair( j� UpgradeAbandon( ) an individual ewage disposal system
at ��'�(f i'>}^r "i ° ! f2. ®q_A l"I/v rt as described in. the application for
Disposal System Construction Permit No. d1' A- C ; dated
Provided: Construction shall be completed within t_ years 0/�,e ate of this permit. All local condi 'ons must be met.
Form 1255 Rev. 5/96 A.M.,Sulkin Co. Chadeiown, MA Date df Board of Health