HomeMy WebLinkAboutApp-Permit-ComplianceNa. gol�'D
FEE
COMMONWEALTH OF MASAS VSETTS
4 ,?(, Board of Health, l �d , MA.
PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to .Construct( ) Repair( ) Upgrade bandonO - ❑ Complete System ..aln vidual Components
Location 6LA) �Brozk
Owner's Name
Map/Parcel# 5
Address T6 66-A, l� f1�rints
Lot#
Telephone#
Installer's Name O-k(x! tUVI (� ty'i,aAj—
Des igner's°Name )Owr.
AddressAddress
3o �Qu�ln,m � 5 fir
q31 mal.`
�- !ox4r./VIvit'
Telephone#
Telephone# 6 _ 11754 -
Type of Building' _ _ Lot Size 2-7 t•
Dwelling -No. of Bedrooms Garbage grinder. ( )
Other - Type of Building No. of persons Showers ( ); Cafetee/ria.
Other Fixtures �� lb
Design Flow (min. required) gpd Calculated design flow Design ;Flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils),
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORAIXERATIONS Z�_ f cl
The undersigned.agrees to install the above described Individual Sewage: Disposal System in accordance with the provisions. of TITLE 5 and;.
further agAees to no to placethe system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed - ll-tAt.�'r Date c
No.A11 }C ^� tQl iP_ FEE
COMMONWEALTH Of MASSACHUSETTS ; "" j;j�k j16 57
0�
Board of Health, )4o4 , MEI. �� \4A
CERTIFICATE OF COMPLIANCE
Description of Work:: /1Cl Individual Component(s) 0 Complete System
The undersigned herebycertify that the Sewage Disposal System; CoaistrIucted ( )', Repaired ( ), Upgraded Abandoned ( ).
at
has been installed rt�,ytccc ;d e with the ovist ns of 3 0 CMR 15.00 (Title 5) and he proved design plans/as-built plans relating to
application +No. t// dated, / Approved Design Flow `,01
Trtstaller 0 -` a"')l /f /
Designer: .,4,SL•i l�ri`(' 1�C1p'1Pft!{"t' Inspector: Date:1.3
The issuance of this;permit shall not be cons ued as a guarantee that the system willfunction as designed.
No. FEE'
COMMONWEALTH Of MASSACHUSETTS
w
Board of Health, y�md(d ilf MA.
DISPOSAL SYSTEM CONSTRUCTION _PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Urade Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No.,, dated
Provided: Construction shall be completed wtthixi-d4eeee-Ve is
}-
Form a.✓255/Rev. 5/96 A.M. Sulkin Co Chad0own,.MA f/Da/te'�."5� ;" / .Boar
d
as described in the application for
oT the date of this permit. All local conditiogs must be met.
of Health