HomeMy WebLinkAboutApp-Permit-Compliance—No. 600c_(1 N5l FEE 6 7 r, 0.0
I,?- / COMMON LTH Of MASSACHUSETTS C (5 I63
Board of Health, 7 %�YiO�'�' , MA.
AP PLICATION OR DISPOSAL SYSRM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairs(} Upgrade( ) Abandon() - ❑ Complete System O Individual :Components
Location
-7 IVOTDl W' m NZ _
Owner's Name /'11N
Map/Parcel#
/ l7J �� i
Address sA/11 E -
Lot#
Telephone#
Installer's Name S'P64k/i,AN �{(,�}L f,�f j/�/f
Designer's Name /1 1,
Address
IS- ,$ ?E4W' 0 A `1 m/9.1i•J1 ro
Address
'telephone#
50 � -,32 6b.s
Telephone#
Type of Building _ _ Lot Size — sq. £t
Dwelling- No. of BedroomsGarbage grinder ( )
Ogler - Type of Btulding 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 ORAITERATIONS AA►cE D� �✓��
The un_ ees to install theabo ib. 0. Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and,
further ees to of to plac em in eraton until a Certificate of Co apliance has been issued by the Board of Health..
Signed Date Ce
COMMONWEALTH Of MASSACHUSETTS 1 ` C6
Board of Health, )6ggM0 LMj , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: U Individual Component(s) 0 O Complete System
The undersigned hereby certify that the Sewage Disposa ystem Constructed ( ). Repaired (X ), Upgraded ( ),Abandoned
by: air',^ /ti t �r -.��,; c c b A-0 A • 5 Pe -t1AN Col,, S "K ,
has been installed ' acc nce with the provi 'ons o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. datedApproved Design Flow (gpd)
Installer
Designer: Inspector:G.Zf)( (,s .'.�•r 6-CjKDate:
The issuance of this; permit -shall not be construed as a guarantee that the system. will function as designed.
No. (9 3q,51 � • f PtK�'4 Iv �dNJVVc_
COMMONWEALTH ®f' MASSACHUSETTS
Board of Health, F°} Q l MA.
DISPOSAL SYSTF'M ONSTRUCTION PERMIT
Y
FEE J
Permission is hereby granted to Construct( ) RepaiUpgrade( ) Abandon( ) an individualsewage disposal system
at `V as described in the application for
Disposal System Construction Permit No/"�P dated
Provided: Construction shall be completed within three years of the date of this Derinit, All local conditions must be met.
Form 1255 Rev. 5/96 A.M.:Sulkin Co. Chadestown, MA Date� J• Boa
�� ! � rd of Health... 4a