HomeMy WebLinkAboutApp-Permit-ComplianceNo. galkpc- 19-Z6a3 -y- 1 , j"S-c� FEE,
COMMONWEALTH OF MASSACHUSETTS c"?o63
Board of Health,MA.
APPLICATION .FOR DISPOSAL SYSTEM ST CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(,,/Upgrade( ) Abandon() - ❑ Complete System tLividual Components
Location
Owner's Name
Map/Parcel# �/%
�/���° _
Address
Lot#
Telephone#
Installer's Name f"�il IS&_
Designer's Name ��� 1
Andress 5 �� fbl�
S a f1yr
Address
Telephone# 0!5j,
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) 33o gpd Calculated design flow Design flow provided 3 S" gpd
Plan: Date L� Number of sheets _ Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator L i Date of Evaluation 6�—
DESCRIPTION OF REPAIRS OR ALTERATIONS _(rte -r /a d! ��✓ J``y`�
The. undersigned agrees.to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE5. and.
further agrees to not to nice the syst m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ///� Date
Inspections
i
�r
COMMONVVEALT14 Of MASSACHUSETTS FEE
Board o fHealth, !? l%%w , MA. 1
CERTIFICATE Of COMPLIANCE
""'—`"Description.of Work: Individual Component(s) ❑ Complete System
,,. The undersigned h eby certiN lhatthe Se Fe Dis osalS stem;: Constructed ( ); Repaired ( ), Upgraded. , Abandoned
at
has been installed i a r ance with the ro�a/$ ns o 10 CMR 15.00 (Title 5) an roved design plans/as-built plans relating to
�r /�
application No. ! dated, % Approved Design Flow (gpd)
Installer r S�
,
Designer: c) lei < 4P& G Inspector: r"J Date: "' :/4;�
The issuance of this permit .shall not be construed as a guaoZe that the system will function as designed.
No. l C-19^'4(053 � FEE' ��
- ' 9
�:O O JLT44 Of MASSACHUSETTS � �'5
Board of Health, YMOV7W
DISPOSAL SYSTEM CONSTRUCTION- PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandcn ( ) an individual sewage disposal system
at D G Ll J- a / _ 'as described in the application. for
Disposal System Construction Permit No. r / / , date
Provided: Construction shall be completed within *U&e& the date of this pei mit -,A11 local corrditi ust be met.
Form 1256 Rev. 5/96 A.M. Sultrin Co. Chadestown,MA D'ate4/ Board of Health