HomeMy WebLinkAboutApp-Permit-ComplianceNo. W O �d DC�4J �� elm{(/ .-� a --OO S 5,5 � FEE "y' W
COMMONWEALTH OF MASSAC1 USETTS
Board of Health, � li' - , MA.Zeae e�3
-APPLICATION FOR ISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairk) Upgrade(-) Abandon( ❑ Complete System AIndividual Components
Location -7
141b" Lam'
Owner's Name
1Bab& ✓ E t-,-) v o
Map/Parcel#
43 ) VS
Address
SA.n l
Lot#
Telephone#
Installer's Name
Designer's Name
fj,^/ c A 0 Lk-,A,C
Address S^�
u j
Address �JD.
{S C �( / '_' �F 12 t� U)
Telephone#
Z jY?,
Telephone#
? o U
Type of Building ?�1. CLC 11"J4 Lot Size sq. ft.
Dwelling- No. of Bedrooms L(- Garbage grinder {
Other Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 1440 gpd Calculated design flow Design flow provided 447 gpd
Plan: Date sh 46 Number of sheets I Revision Date
Title
Description of Soils) af'e V LA11j
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The u grees to inst ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
" further ees to of topl cys
a t in operation until a Certificate of ompli ce has been issued by the Board of Health.
Signed Date
Y.
No. C! 'G ee O FEE 5 � 60
,
f/ _ COMMONW LTH Of MASSACHUSETTSAS 1�
Board of Health, 7 &,M0li 0 4 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: individual Component(s) O Complete System %� Cy l
, ® 5
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded ( ), Abandoned O �%
at -2"7 :�-,P"ia ('C_Q
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. %' G` dated 1_�1�%Approved Design Flow (gpd)
Installer -DA, i\�
Designer: Inspector: W.d' %' Date:
The issuance of this permit, shall not be construed as a guarantee that the system will function as designed.
No. A c-" c� t�� 2 '- J ;` _ � \ K � (i i v FEE a v 1
iF `7 COMMONWEALT14 Of MASSACHUSETTS
Board of Healtlt, �/00714- , MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gran Led to; Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
at`— a`\+ � W as described in the application for
Disposal System Construction Permit No. �` dated
a� e
.Provided: Construction shall be completed within_ sSyo theSdate of this nernit. All local conditions. must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Y _) '/ Board of Health
. i f
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