HomeMy WebLinkAboutApp-Permit-ComplianceNo. 66WIDC-41-1(331-7
FEE
�1-- /W COMMONWEALTH OF MASSAC14USETTS CDS R)0101
Board of Ilealth, Am.
me z r '14W
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) RepairW) Upgrade( ) Abandon( . ) - Ll Complete System �Individual Components
Location Aj0dj
Owner's Name
Map/Parcel#
Address 3(e De2(-�°ed pi gy,
Lot# 15
Telephone# L//) -57,3& -
Installer's Name &4.14 at)Sf —,3-71c
Designer's Name
Address
Address
Telephone#
Telephone# - 5b8-
Type of Building Lot/0 P,�V f .Size - q. ft.
Dwelling - No. of Bedrooms -3 Garbage grinder
Other - Type of Building No. of persons Showers O, Cafeteria
Other Fixtures
Design Flow (min, required) 530 gpd Calculated design flow Design flow provided gpd
Plan: Date /5. wi Nurnbjr of sheets Revision Date
Title
Description of Soil (s) �V)110
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to' allt
,>e above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t lace too"system in operation until a Certificate of Complian7 has been issued by the Board of Health.
Signed . ... .... . ... Date
FEE (X)
No.
COMMONWEALT14 OF MASSACHUSETTS
/*7,0 0
-
Board of Health, )Lpr-?�M_ D MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 01ndividual Component(s) U Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (AY Upgraded( ),Abandoned(
by:
at
has been installed aur. accordance with the provisions of 310 CMR 15.00 (Title 5) and thq approved design plans/as-built plans relating to
application No. dated 4, Approved Design Flow i t,-, (gpd)
Installer
o07 011/ 0a
Designer: . 'Y ns ector: 'ev Z
J] p Date:
The issuance of this permit shall: not be construed as a guaVt*ee that the system will function as designed.
No.''` FEE
I
COMMONWEALTH Of MASSACHUSETT S
Board of Health, VAzm n o121 , Am.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to.; Construct( Repair( -1) Upgrade( Abandon( )an individual sewage disposal system
at
as described inthe applicatioln for
Disposal System Constriiction Permit No. dated i
,7
'It
Provided: Construction shall be completed within,;t s
alre ars of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Chadeslown, MA Date
,7 Board of Health