HomeMy WebLinkAboutApp-Permit-ComplianceNo. b04bC—iSZ 6(010
, c--,3Vll MVINI ?iNTS%IUA TT.1iJnr _VTA.Q0ZA f "TAT 1QFT 'Q
Board offlealth, 4�c, t-Moc'�-1, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
A plication for a Permit to Construct( ) Repair(_j Upgrade( ) Abandon( ) - ❑ Complete System .Individual Components
Location
h
Owner's Name '
Map/Parcel#
Q
Address 3
Lot#
Telephone#
Installer's Name
;
Designer's Name
Address LAL4Q
e„+�
1 G
Address
Telephone# .
-05. q,7,71
QG
Telephone#
Type of Building 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)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OFRL'PAIRSORAITERATIONS�c��o�CC. `Z�c. �c^1t.hccn Z Cc�SAoo�S
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed &Go,2eSY Date 12-L- 1'8
No �'? l.) t' l k (. . 4 Cw. �G' }(m .✓ V”, !°( re```"W\-^'"'6l�
ICL
COMMONWEALTH OF SSACHUSETTS
(
sf
Ar
Board ofHcalth, tF)a; r* r<)r r)l•M , MA. �
CERTIFICATE OF COMPLIANCE
Description of Work: _ El"individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (G.=Y) Graded ( ),A andoned ( )
by, `"� `=.. ids r':"."l(' I1 1,a T:, -)N\
has been installed !m acgw-clauce with the Provisions ofA10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No 1'ri "'-.y fd_ dated a e�.. ?�" /e Approved Design Flow ' (gpd)
Installer
Designer: Inspector: Date: /. .....
The issuance of this permit shall not be construed is a guarantee that the system will function as designed.
No.
a COM ONS -11 OF MASSACHUSETTS
Board of Flealth, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FLrII
la11: �.
Permission is hereby granted to; Construct( ) Repair(- Upgrade( ) Abandon( )an individual sewage disposal system
Disposal System Construction Permit No.
�.
dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkln Co. Cheheslavn, MA Date/' Boardof Healthi'-