HomeMy WebLinkAboutApp-Permit-ComplianceNo.FEE 5 S 100
COMMONWEALTH ®MASSACHUSETTS.
Board of Health, qo yyn p*h , MA.
APPLICATION.FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for aPermit to Construct( ) Repair�l Upgrade( ) Abandon( ) - ❑ Complete System lolndividual:Components
a Location
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Map/Parcel# �% ` d
-
Address �� f- f �S ! n! b�
Lc�t#
Telephone# S 08-3140 - 503
Installer's Name Po 6yr 0,l�°r ���
Designer's Name
Address Z FJ (2.°G� moi'` ej i s
Address
11 Telephone# Sof -5-p - p 4�
Telephone#
Type .of Building' S; pbm P ✓
Dwelling - No. ,of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan:' Date
Jatet� iX'ej'lcs� Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS AO -AW -e- �h t f n -e, Cots T
o uns' (Aa hyB -m Q* p Ti C d eL.g,
The undersigned agrees to install the above described Individual Sewage.Disposal System in accordance with the provisions of TITLE 5 and;
further agrees to njo�t-�toolace the/ system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed derv- Date
No. Q o v - I COMMONWEALTH OF MASSACHUSETTS SETTS FEE && 5 Q
Board o f Health, Y1�AIN-0 B J t wn , MA.
CERTIFICATE OF COMPLIANCE �
Description of Work: Q&Individual Component(s) ❑ Complete System Zi6)Abb&ando�f
The Lun��ersigned hereby certify that the Sewage Disposal System;. Constructed ( ), Repaired (X, Upgraded ( , (
by: f'`� wr 49 • T`tie,
at &44w1
has been installed in accord,9.Ree with the Provisions of 310 CMR :15.00 (Title 5) and the ;approved design plans/as-built plans relating to
application No, dated.L11 Approved Design Flow (gpd)
Installer Q 0Q.-
Designer:
Q. Designer: ""''"..._. Inspector:e thaDate: on, .7 !�
The issuance of this permit shall not be construed as a gu tet the system will function as designed.
FEE
COMMONWEALJH Of MASSACHUSETTS
.Board ofHeearlth, Y A -(Z ®L �1 4- y �T MA.
DISPOSAL SYSTEM STEM CONSTR U CTIO Y PERMIT
Permission is hereby gran ted to;; Construct( ) Repair(') Upgrade{ ) Abandon( ) an individual sewage disposal. system
at
,„5 &g/ as described in the application for
Disposal System Construction Permit No.dated co
r.
Provided: Construction shall be completed within-tlr aVof Elie date of this vee rmit. All local � nditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkln. Co. Chadestown, MA Date .� / card of Health