HomeMy WebLinkAboutApp-Permit-ComplianceNo. �"Dc - 19 —3 v! / FEE':
1-'A�)T9,- ( 9 3 COMMONWEALTH OF MASSAC14USETTS C.*V 36*'
Board of Health, VA? -Mo V , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgradet//Abandon( ) -/complete 0 Individual Components
Location ��,4! %'
/Yj.b l � /
Owner's Name le
Map/Parcel# l46ao
7aA
Address /%A/t %/ 4,a J -T
Lot#
'Telephone#
Installer's Name Qd✓ f'46IX- ep-
Designer's Name
Address T-11
Address
Telephone# f"Gy t'— 9
_-rk 70
Telephone# -113 X J-'
Type of BuildingA -e Lot Size i 747 r sq. £t.
Dwelling -No. of Bedrooms' Garbage grinder. { )
Other - Type of Building Q No. of persons Showers O, Cafeteria. ( )
Other Fixtures -0,
Design Flow (min. requi ed) � �' g d Calcu ted design flow Design flow provided gpd
Plan Date % % Number of sheets _ Revision Date _VA
Title
Description ,of Soil (s)
Soil Evaluator Form No. Name, of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The: undersigned,agrees to install the above described Individual Sewage Disposal System in: accordance with the provisions. of TITLE 5 and
further afire of f�I e ee tem in operation until a Certificate of )mnLance has been issued by the Board of Health.
Signed Gt/G%��'°' Date
No. ! , FEE
/r fJCOMMONWEALTH Of MASSCJTT f£. �,
f r .,• /
9w,
Board of Health; YAtzriIOUTtf
CERTIFICATE, Off' COMPLL T\TC E
Description of Work: U Individual Component(s) mplete System✓Y C� d'F' ` r �`G7 �"
The u�nde•-r-si ned hereby certify that the Sew -Age Disposal S stem; Constructed Repaired Upgraded Abandoned ( r
( ).
by �p js• �t/.d %/� d /al C•x✓.� Ia•�- , lift
has been installed in acco ance with the provisions of 3-1,0 CMR 15.00 (Title 5) an t e;appr ced design plans/as-built plans relating to
application No. �Q` f , dated - % Approved Design Flow gpd)
Installer -�i
Designer: ► Inspector,
Date: 7.: :/7
The issuance of this permit shall not be construed as a guar5ntee that the system. will function as designed.
No. 60 H C7 C l TE�iAZ"t lei 11CeV- e� CA V 1 FEE
COMMONWEALTH Of MASSACHUSETTS
213ry
Board ofHealth, f1�12J1'lOt1 i`I % MA.
DISPOSAL SYSTEM CONSTRUCTION -PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade.( - Abandon( ) an individual. sewage disposal system
at e' /V O%1 �'I / �� r77)as as described in the application. for
Disposal System Construction Permit No//1� ' dated �.-��
Provided: Construction shall be completed within 996
Provided: date of this permiu-AlI local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Go. Chadestown, MA Date. 1 _/ Board of Health
O