HomeMy WebLinkAboutApp-Permit-ComplianceNo.- AA -X-« 275 FEE' 55 �
COMMONWEALTH Of MASSACHUSETTS 0173`x.
Board of Health, ) 0MA.
APPLICATION.FOR DISPOSALS
ST I CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon() - mplete System O Individual Components:
Location_ W
Owner's Name
Map/Parcel#
Address ?-Z
r,,QLCGt� t -N- OIA-In
Telephone#
Installer's Name R'1 C-
Designer's Name
Ssc
Address
zxs�o t 1�� 11S
3r1 Address
24�•
Telephone# d d
Telephone#
Type of Building Les Lot Size 10i SOO 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 L%�� Design flow provided 4 5-5- gpd
Pian: Date ,I Number of sheets _l Revision Date
Title , ((
Description of Soil(s).
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS .OR AI TERATIONS
The. undersigned:agrees to install the above described Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 and;
further a e to pla . the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections.
No. C560C. l Ci -275 FEE S-�J
COM ; NWEAI.TH Of MASSACHUSETTS
Board of Health, Ywwam , MA.
CERTIFICATE OF COMPI ANCE
Description:of Work: ❑ Individual Component(s) Elydmplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), .Repaired { ), Upgradedo, Abandoned
by E 0
1
at
has been installed inntacco ance with the proNdsions of 10 CMR 15.00 (Title 5) and tth'e�approved design plans as plans relating to
application No. 7' ` dated + l ~` Approved D. sign FlovI7! � y—(gpd)
Installer
Des#gner: 66 C C'siZ t) 0 P Inspector~ Date:
The issuance of this permit shall not be construed as a guaran ee that the .system will function as designed. F_
No. \X t9 -Z. 577 - j U I:EE l tJ
�-
COMMONWEALTH Of MASSACHUSETTS Chi
Board of Health, Y jolJ--;+ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(
at
Disposal System Construction Permit No.
Provided: Construction shall be completed within
Form 1255 Rev. 5196: A.M. Sulkin Co. Chadestown, MA Date
Upgrade Abandon( ) an individual sewage disposal system
as described in the applicationfor
dated''?' Z .b
of'e: date of this per it, All local conditions must be met.
Lard of'Health
% ,