HomeMy WebLinkAboutApp-Permit-ComplianceNo. I3L DT G - 60 6 3�d FEE
���0� CY0S _M[® 1CTH ® MASSACHUSETTS
Board of Health, yar r -NoLAk NIA.
APPLICATION FOP DISPOSAL SYSTEM CONST UC IIT
Application for a Permit to .Construct( ) 'Repair(sejooUpgiade( ) Abandon( ) - ❑ Complete System O Individual Components:
Location \
Owner's Name 10( i, r -
Map/Parcel# t (y . $
address L43 AV%Or Lv--)
Lot*
Telephone#
Installer's Name .fEY.c=03-A; o A
Designer's Name
Address cf LtJ O�'CS
L Address
Telephone# e) 7 ,
Telephone#
Type of Building — R=;C1CM;Ct_1 - Lot Size sq. ft:
Dwelling - No. of Bedrooms`3 Garbage grinder ( )
Other -Type of Building No. of persons Showers (' ), Cafeteria
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow Design flow provided 3SCj gpd
Plan: Date Number of sheets _ 1 Revision Date
Title
Description ;of Soil ('s)'
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 14ZO n BW_- " I L. A 2 0 )C -xnA-i j 4 ra Aor- S
The undersigned; agrees to install the above described Individual Sewage.Disposal System in accordance with the provisions. of TITLE 5 and;
further agrees to not to place the: system in operation until a Certificate of Compliance has been issued by the Board of Health.
" Signed,_ Date
Inspections
No. k5!Z OLD
V_� a t lU COMMONWEALTH O �ll�' SSACH IJ SETT �� EEE
oit
Board of Health; , i An 0 /j j �, . , MA.
CERTIFICATE OF COMPLIANCE ID
Description. of Work: @rIndividuai Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ).,.Repaired („+Y Upgraded ( ), Abandoned
byigr<'-:` r, teats
at
has been installed in accordance with heprovision of 310 CMR :15.00 (Title 5) and the roved design plans/as bulli plans relating to.
application No. datedpproved Design Flow (gpd)
Installer x C.r+ j-I,A:A n r%_
Designer S)z.)r 01A50K) Inspector: & Date.: ".
The issuance of "permit shall not be construed as a guarantee that t . e system will function as designed.
No, �� �-1 3i I(0 FEE t i
COMMONWEALTH OF MASSACHUSETTs
Board of Health, L -L r r n,D, A , , Na.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;; Construct( ) Repair(,, -Ie Upgrade( ) Abandon ( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. /,-,I dated �✓
p rel` ela s of fle date of this perm't. Ail local conditions must be met:
Provided: Construction shall e completed within
Form "1255 Rev. 5196 A.M. Sulkin Co. Chaletown, MA 1)ate�77, oard of Health '