HomeMy WebLinkAboutApp-Permit-ComplianceNo. G_ K_34011 1/ve1 fee FEE i
COMMONWEALTH OF MASSAC14USETTS 0�0e>
Board of Health, � � Gj'11-114, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(y Upgrade( Abandon( - 0 Complete System 4Individual Components
Location (
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Owner's Name-EO��tC Iv( Lj�E
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name
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Designer's Name A -
Address r
RSL-�
s Address
Telephone# ibZ
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'Telephone#
Type of Building �Z��"L�`hr- 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) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS __0SV-- �t�V`'
a4 ,,-p iiu S—i4-cmc, z—& -e A-5 iy
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until Certificate of Compliance has been issued by the Board of Health.
Signed Date J —177AQ 14
Inspections
2 •
No. J FEE
COMMONWEALTH OF MASSACHUSETTS
f Board of Health,
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s), O Complete System e �-
The undersigned hereby that the Sewage Disposal System; Constructed ( ),Repaired (, Upgraded ( Abandoned ( )
by:
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PEU- t l76 Q t' !>- i c kh5
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has been installed in Gorda ce with the rovisions of 31.0 CMR 15.00 (Title 5) and th�proved design plans/as-built plans (elating to
application No. i `� dated !2 `7. Approved Design Flow (gpd)
Installer 9l,()f E 8c) zlAE)tj
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Designer: N�4 Inspector: .rt, � Date:._
The issuance of this permitshall not be construed as a guarantee that th system will function as designed. f
No. �) De'l�- joy / ,1_f✓O'(-jjr__�t� FEE
COMMONWEALTH Of MASSACHUSETTS
Board ofHealtli, 'YARazb anP m -A.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is herby granted to; Construct( ) Repair( X Upgrade(
pgrade( ) Abandon ( } an individual sewage disposal system
at b- UAPT �/�! - ! 2�5 3 �% as described in the application for
Disposal System Construction Permit No. `s % , dated 47-
Provided: Construction shall be completed within tNg e' 8 tfie cote of this p mit. All local conditions must be met.
Form 1255 Rev: 5/96 A.M. Sulkin Co. Chaileslown, rta Date '' ! Board of Health %.lr�