HomeMy WebLinkAboutApp-Permit-ComplianceNo. C" 19 •7 s: l '�- ''% FEE 'fes OV
COMMONWEALTH Of MASSACH /SgsSBoard of 1lealth,i�-Q.{�f� MA.
APPLICATION FOR D�� OSAL SYSTEM CONSTRUCTION 'RMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon O El Complete System Individual Components
Location
O� �'o�, `/
Owner's Name C
Map/Parcel#
Address
Lot#!
Telephone#
Installer's Name
�/i 4>fe �.
Designer's Name
Address��✓��
�' r P�,1 t 4
Address
Telephone#
i Telephone# Z r yr y
Type of Building Lot Size sq. ft
Dwelling - No. of Bedrooms 3 Garbage grinder(
Other Tvpe of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) _220 gpd Calculated design flow Design flow provided l gpd
Plan: Date Number of sheets / Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of.Soil Evaluator 4 • i5 ref -614-L6 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS LI, W�
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 ace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date // - /Ir
Inspections
i r
No. CA • DC EEi1tJ
a
COMMONWEALTH OF MASSACHUSETTS J141
at: IT
Board of Health, )1APAbl311A , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: "dividual Component(s) ❑ Complete System r�
The undersigned hereby certify that the Sewa a Disposal System; Constructed ( ), Repaired ( UpgradedW, Abandoned
by:
e �� f 1i✓l./"
at 3 ,S' • �. v
has been installed in accord ce with the rovi, ions of 3].jd CMR 15.00 (Title 5) a th approved design plans/as.-built plans relating to
application No. c, dated � /_ �14 `/4 Approved Design Flow"7
(gpd) ,
72? .,
Installer u!t'� T —w2ex a�
���� g
Designer: !1.3{a/, Ir- Inspector:. i Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. FEE
lY
l�i ��''�)i° �"'��.--Cy�� ��� :.
COMMONWEALTH Of MASSACHUSETTS
Board of Health,'l.®l7- , MA.
DISPOSAL. SYSTEM C®NSTRUCTION_PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at L Zx, t. e,
J as described in. the application for
Disposal System Construction Permit No. 1 _ _,)9 � , dated � _'J
Provided: Construction shall be completed within t __sof 0,e date of this rt'it. All local con 'ons must be met..
Form 1255 Rev. 5196 A.M. Sulkin Co. Chadestown,MA Date / Board of Health l
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