HomeMy WebLinkAboutApp-Permit-ComplianceNo:-06z)q
tq - 0013c4VOMMON LT Of MASSACHUSETTS
Board of Health, YAR^oon4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System O
FEE', 5
l t �2v
RECEW- ..
JVNI 18 ?019
HEALTH DEPT
�_ �, %�'I
'._
' I ' A01VW NOWiI/
Designer's fl�iirl/ 'lowW/
Type of Building N- --
Dwelling-No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min i equir d) gpd Calculated design flow Design flow provided �� gpd
Plan. Date Number of sheets _ c Revision Date
Title
Loc Size ' ! sq. ft.
Garbage grinder ( }
Showers (), Cafeteria
Description of Soil(s)'X 16 4:14W
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersiafire to install the above described Individual. Sewage; Disposal System in accordance with the provisions. of TITLE 5 and
further afire . to ne t in ope ation until a Certificate of Compliance has been issued by the Board of Health.
amu,
Signed, Date
Inspections
COMMONWEALTH OF MASSACHUSETTS
a __, � C �2-
Board of Health, .60 T V , MA.
CERTIFICATE OF COMPLIANCE
Description -of Work: ❑ Individual Component(s) Complete System
The undersigned herebv certify that the Sewage Di:
at
has been installed ` acconce with t11e
applicatiotu.No.. �y�r� � dated
Installer7�//
System; Constructed ( ), Repaired ( ), Upgraded(,/), Abandoned
1 CMR .15.00 (Title 5) and thea roved design plans/as-built plans relating to
Approved Design Flow (gpd)
Inspector:_
Date:... "/..""
The issuance of this permit shall not be construed as a guarant6e that the system_ will function as designed.
No.
COMMONWEALTH. Of MASSACHUSETTS
Board of Health, V MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE'
Permission is hereby granted to Construct( ) Repair( ) Upgrade ( ) Abandon( ) anindividual sewage disposal system
at J C) ` J }�� ��f Ql� �=E' � as descrtbec4 in the application for
Disposal System Constt uction Permit No. dated 7—
r
Provided: Construction shall be completed withit�,,Jb e .'flihe date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin. Co. Chadestown, MA Date 7"/0 Board of Health / / % yam' A
r