HomeMy WebLinkAboutApp-Permit-ComplianceNo. OOA+D C - N -O beo5 / le— �Z_D— do 0//-�� EE
T I � K:
COMMONWEALTH OF MASSACHUSE
Board of Health,Zi�" , MA.
r.
APPLICATION AOR DISPOSAISYSTEM CONSTRUCTION PERMIT
a Ap lication for a Pei•tnit to Construct( ) Repair( ) Upgrade(v� Abandon( - ❑' Complete System "dividual Components.
Us`
'ovation
�,�
Owner's Name
r
/•Q
Map/Parcel# 9-
7
Address
_
Lot#
Telephone#
Installer's Name
Designer's Name
Address Aq
Address
4,(""AZ Ah
Telephone# D
)
Telephone#
7191) , . - �_dj
Type of Building Lot Size sq. ft..
Dwelling- No. of Bedrooms' Garbage grinder ( }
Other - Type of Building No. of persons Showers (' ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) S,3 U gpd Calculated design flow Design flow provided gpd
Plan: Date :2- a Number of sheets _ � Revision bate
Title
Description of Soil(s)', � _C" f r✓ / ria
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS zT�� / N 1,0L / J JJ
,The: undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 51 and;
further agrees to not,tlace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �/-�% Date
Inspections %: / � /!// /% . /J IF
No. GL/
COMMONWEALTH Of MASSACHUSETTS ��`1 713
Board o Health; , MA.
f I���
CERTIFICATE OF COMPLIANCE
Description.of Work: El Individual Component(s) ❑ Complete System
The undersigned hereby certifyaat �h wage o sposal System; Constructed ( )', Repaired ( ), Clpgraded Abandoned
by: % e T r
at
has been installed in accordance with the ro�isions of CMR 15.00 (Title 5) and t e approved; design plans/as-built plans relating to
pp ,/ ' ;� . Approved -Design Flow (gpd)
application No. ,�..F % ,dated ',r
installer A41 i' k
Designer: /< / , Inspector: ,Date,: 'Z
The issuance of this ;permit shall not be construed as a gnat tee that the. ystem will function as designed. `
No. 9 —60 55 ��� � FEE ,00
7 COMMONWEALTH OF MASSACHUSETTS Ck,-�-- -7131
Board of Health, yAgNourp— , Am.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby.granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual: sewage disposal system
at l.- 6 i f� �,,11 Fw1 G as described in the application. for
Disposal System Constt uction Permit No. /j, 7 , dated
Provided': Construction shall be completed within d arKf'£he date of this permit. All local conditions .must be met.
_ 6
Form 1255 Rev. 5/96; A.M. Sulkln Co. Chadestown, MA Date�:�) Board of Health 4� Ll