HomeMy WebLinkAboutApp-Permit-ComplianceNo. 13Q�� 9 Z~ �l v''GC /\.�� ��T �� FEE'5'&V
j9 / e Mi VW)NATTI.TH AI` AAWNACHITIQUTTIQ 0q5-1,-0
Board of I-Iealth, �OU� MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair{UpgradeO Abandon( - ❑ Complete Systemx®�idivitdual Components.
Location 60 Cv-,r-Ue 4t 1 (
Owner's Name
Map/Parcel# 1 c7
Address 4rye- H 1,N W.r ,M,®V
Lot#
Telephone# 4 ) '7.. 7,Y,3_ 3894
Installer's Name �� .� Our (6 -rnG.
Designer's Name
Address 7,q 6r�- o�
- A , 14cav 1 � AA,4 ,
Address
Telephone# So 0 v -71- 0
Telephone#
Type of Building
Dwelling - No. of Bedrooms .
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description ofSoil(s)
Soil Evaluator Form No.
Lot Size sq. ft.
Garbage grinder { )
No. of persons Showers( ), Cafeteria ( )
gpd Calculated design flow Design flow provided gpd
Number of sheets Recision Date
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ('fA (te /tai A I - n e- 00+-5,06 40,)5 7
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with theprovisions-of TITLE 5 and
further agreestonot to pI ce thsystem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �LU'SIN . r J. M 69. tr/ Date q" /-/I
Inspections
No. lir(i4i Q,( t- A (o l
"
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ��gr>r,rl L T44
CERTIFICATE Of COMPLIANCE
FEE -:-7W
& 0qS /0
Description of Work: V1ndividual Component(s) 0 Complete System J1 e4z/_1 44/1
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ()V, Upgraded ( ),Abandoned O
by: &66c, � a tr Iri,
at (r w- /' z „40 -i s I/ I&
has been installed in accordance with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. t!%� dated It ' S "/ Approved Design Flow (gpd)
Installer
Designer: "'""' Inspector:. �.�C/�(����� �' Date:.
The issuance of this permit shall not be construed as a guarartiee that the system will function as designed.
No } __ cl f_1 C-0 FEE
��I G COMMONWEALTH Of MASSACHUSETTS C �� Ocj5-70
Board of Health, Y 'iQ QT -P , MA.
DISPOSAL SYSTEM CONSTRUCTIONPERMIT
Permission is hereby granted to; :,Construct( ) RepairQV-) Upgrade( ) Abandon( ) an indiv dualsewage disposal system
I
at L, f a -E ye A. It eA �^ as described in the application for
Disposal System Construction Permit No. f 60
/ 01_, dated
r '
Provided: Construction shall be completed within €k• A oeihe date of this permit. All local conditions must be met..
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChMestown, MA Dat . ..� % Board of Health