HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE'; l75 . .
l9-fS' COMMONWEALTH OF MASSACHUSETTS
Board of Health, L09=1M0 0 �13 , MA.
DISPOSAL SYSTEM CONST UCTION! AE
Application for a Permit to Construct( ) Repair( :) Upgrad O ndon❑ Complete System U Individual Components
Locatioa 'dl , ri ar6rtj e.
Owner's Name
ke( o Car
Map/Parcel#�
Address �q
Lot#
Telephone#
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Itrstaller's Name M rnQ� �—
Designer's Name
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AddressJo j 0A IMA
Address
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A OL 99— S Af(l
Telephone# , (
Telephone# ,
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Type of Building' _ n - -- _ Lot Size sq. ft..
Dwelling - No. of Bedrooms Garbage grinder
Other -Type of Building No. of persons Showers (' ), Cafeteria
Other Fixtures 1^h
Design Flow (min. required) gpd Calculated design flow Design flow provided C)01- .� gpd
Plan: Date Number of sheets _ Revision Date
Title
Description of Soil(s)'
Soil Evaluator Form No.
Name, of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS t(_
Date of Evaluation
The undersi ed,agrees to install the above described Individual Sewage;Disposal System.in:accordance with the provisions of TITLE 5 and,
further agr s t not to Mace ,the t/e�m� operation until a Certificate of Co pliance has been issued by the Board of Health.
Signed.` L ` �"""�� Date
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1(0
106
Boar's o f Health, Y OQM , MA. o
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CERTIFICATE OF COMPLIANCE
Description of Work: i ndividual Components) El Complete System
Theundersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgradedv Abandoned {
by:rr 1 k i'i ` f 1` ;1.1 r4 '1 3't �'1 �.{ t.+ ('"""
t1 4
at , 1 �i ►' 4 fZ 4' ! 1 i L�-1 e
has been installed in accord
application No. ./ Of -E"
Installer `ii_ kw
with tite risions of 310 CMR 15.00 (Title 5) and the approved, design plans/as-built plans relating to
dated �prot...�. d!—jr�Approved Design IPow ,1-)�,� (gpd)
Designer: t . CO 1;;_�-u+ inspector: K 0,� Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as desired.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, T .IY18t17- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE 00
is hereby granted to;; Construct( ) Repair( ) Upgrad6o Abandon( ) an individual sewage disposal system
-- as described in the application for
Disposal System Construction Permit No. Z± dated�'
Provided: Construction shall be completed within 9"a Ae date of this permit. All local co. ditions must he met.
Form 1255 Rev. 5796 A.M.:Sulkin Co. Chadestown, MA Dat b1 oard of Health
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