HomeMy WebLinkAboutApp-Permit-Compliance'vote ?/`-'—Y� Zuq X -o [ DTV I q ' 0051 Cn FEE'
No. �Ox -f ZAoA,
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COMMONWEALTH .TH OF MASSACHUSETTS Ck4G15 14
Board of Health, yarin no- 6, , MA.
APPLICATION FORDISPOSAL SYSTEM ST CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(✓<Upgiade( ) Abandon( - O'Complete System O individual Components
Location `1 &
An -A 1 cr s
Owner's Name 12 G
Map/Parcel#
$ _
Address 41, Arvikiis
Lot#
Telephone#
Installer's Name,
XC0.VG3l'� O{1
Designer's' Name0. m
.Address
114Address
a,5c's'rda c_
oPcs
Telephone#
„ Q1,5
Telephone#
Type of Building RcS i ctcx- 1 t 0. 1 Lot Size . O. _ sq. ft.
Dwelling- No. of Bedrooms Li Garbage grinder
Other -Type of Building No. of persons Showers ( ),, Cafeteria
Other Fixtures
Design Flow (min. required) H 4 O gpd Calculated design flow Des ign'flow provided yss gpd
Plan:Date 31 ISI 1 is Number of sheets _ Revision Date
Title
Description of Soil (s)'.
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS OO 1410 $'T }A 20 � o X - 2 - SOO
The undersigned.agrees to install the above described Individual Sewage Disposal System in,accordance with the provisions of TITLE 51 and;
further agrees to not to pylace thesystemin operation until a Certificate of Compliahce has been issued by the Board of Health.
Signed 1' 1�— Date
Inspections.
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No..BL t. I — 2 -1 FEF � � 5
f,�®�®�T ���ASSAC�JS�TT�
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.-� Board of Health; bfA.
CERTIFICATE OF COMPPAINICE
Description of Work: ❑ Individual Component(s) 0Komplete System
The undersigned hereby certify. that the Sewage Disposal System; Constructed ( ); Repaired (✓)✓ Upgraded (Abandoned ( ).
by: OC
at
has been installed in accor&94,e with the provisions of 3 0 CMR 15.00 (Title 5) anj the approved design plans/as-built plans relating to.
application No. , dated . Approved Design Flo (gpd)
Installer r, -ti -a 1 n.^, �4�C 'r" r<1 t )ti
Designer: D-til)C' ^� Inspector: _ T� �./tr d Date:
The issuance of flus ermit shall not be construed as a guaraC ee that the system will function as designed.
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No. (6-r, kA f 1 �1- - A -k E�kC A
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COMMONWEALTH Of MASSACHUSETTS
FEE - X5,,0
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Board of Heearlth, �- � � > MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(,./ Upgrade (Abandon ( ) an individual sewage disposal system
at_ 91, A r>A -1 , as described in the application for
Disposal System Construction Permit No. Zf- , dated ,:�-�
Provided: Construction shall be completed within threeoF'tthe date of this,per it. All local conditions must be met.
Form 1255 Rev. 5/96' A.M. Sulkin Co. Chadestown, NIA Date `/� Board of Health