HomeMy WebLinkAboutApp-Permit-ComplianceNo. 601+Dc- 18-619q 17 LD 1z.-1 t —00 (11-7 EEE ;00
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Board of llealth, �PJLKD1YM , MA.
APPLICATION FOP DISPOSAL SYSTEM CO
NSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(.) Upgrade(�O bandonSystem ❑ Individual Components
Locatio ev
Owner's Name S
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name J/A
esigner's Name F�
..Address � % � �
Address .d. -13.x
Telephone#
Telephone
Type of Building a�!!S11,0 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) �s✓7 gpd Calculated design flow Design flow provided gpd
Plan Dat,,� -LF � �CJ/� Number of sheets '2- Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS C,4141^7,
The undersigned a ees t*uistthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire o t to tem in operation until a Certificate ^of Compl&nce has been issued by the Board of Health.
Signed Date 3
Inspections
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COMMONWEALTH
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<." '1.®1"lll�ll'Url� V'V' LTH 'USF MASS 1'L HUSET I.
Board pouf, Health, ^� �1 E Of COMPLIANCE,
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Description of Work: ❑ Individual Component(s) 016omplete System
The undersigned hereby certify. that'the Sewage Di posal System; Constructed (, Repaired ( ), Upgraded ( ), Abandoned ( )
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has been installed i1 ac or e with the p pvisions of 31 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No. dated "" proved Design Flow (gpd)
Installer �" �7 / /?S r' ,
DesignerLCAS 4C4zV.CV -75u .. Inspector: %d o " Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
Nom Q A TO C �' .--0 i -7 CA t t JA L J� s FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �)W= Moym� , MA.
DISPOSAL SYSTEM CONSTRUCTION I PERMIT
Permission is hereby granted to; Construct(k< Repair(vif ` Upgrade ( ) Abandon ( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. -?4W , dated
Provided: Construction shall be completed within 41we4l a s of thrdate of this per t. A.11 local coed' 'ons must be met.
Form 1255: Rev. 5/96 A.M.`Sulkin Co. Chailesl0W0, MA Date �BO
'ard of Health