HomeMy WebLinkAboutApp-Permit-ComplianceNo: Po w D C—1 l'_�✓ *w/ �i�ie '/ FEE;
COMMONWEALTH OF MASSACHUSETTS cw-1 y ?
Board of Health, 1t 1bLU1i MA.
APPLICATION.FOR DISPOSAL SYSTEM CONSTRUCTION P RMIT
Application fora Permit to Construct( ) Repair(�grade( ) Abandon( ) El Complete System Individual Components
Location:
Owner's Name D 7 S 7 q cc � S
Map/Parcel#
Address
Lot#
Installer's Na//mC��,,e Ca f �a ' �"C�. Z- L5 e _
,.elTel�ephone#
c..eeesigner's Name
Address _V ( C.�(N( ��
Address
Telephone#'D$ 2 2-51-00
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) gpd Calculated design flow Design 'Elow provided gpd
Plan:' Date Number of sheets _ Revision Date
Title
Deseiption of Soil(s)'
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaltiation
DESCRI��P//TION OF REPAIRS OR ALTERATIONS
4" k e'y U t uhf
The: undersigned a t install a above d scribed " -i nal Sewage' Disposal System,in accordance with the provisions of TITLE 5 and,
further agrees to oto a systexn�;'., ~� on until a Certifcateof TChai►ce has been issued by the Board of Health.
Signed Date
ddLL�?S5 `�
Inspections. r 0 e
/-
No., E304-Dc—lcj--zS143 FEE QQ
t.
COMMONWEALTH OF MASSACHUSETTS
Board o f Health, t�12M01T , MA. NA
CERTIFICATE OF COMPLIANCE
Description of Work: W Individual Component(s) ❑ Complete System
The a dersignec� herel ertify. that the Sewage Disposal System,; Constr cted� ), Repaired Upgrade O,Abandoned
�}`� C.E J Q 1 P f c� P Ccs f' �"i' (1 tt7.
by: v.
at
has been installed in accordance with the provisions of.3.j4) CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated. 2 7 T Approved Design Flow (gpd)
Installer aj —T O L
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. c)to -DC '« "2, s -q-3 Gwe CM ze l i C. ( t -Z'%1 ecN) Ci �'j FEE
COMMONWEALT14 Of MASSACHUSETTS _g? q?
Board of Health, 7 a�i%%�' , NM.
DISPOSAL SYSTEM STEM STRUCTIO - PERMIT
Permission is he by gran ed to; Construct( ) Repair( upgrade(
) Abandon( ) an individual sewage disposal. system
at as described in the application for
Disposal System Construction Permit No. , dated.
Provided Construction shall be completed within three years of the; date of this ,per it' I local c d' ' ns. must be met.
Form 1255 Rev. 5196' A.M. Sulkln Co. Chadestown, MA Date y Board of Health