HomeMy WebLinkAboutApp-Permit-ComplianceNo. 'Y/�� V /�`b v- V U V to (ta FEE'„
COMMONWEALTH OF MASSACHUSETTS 001170
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Board of Health, Y LTJ MA.
APPLICATION F® DISPOSAL SYSTEM CONST 1 JCTI0N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgr:a andonO - O'Complete System .2 i dividual Components
Location: 33 ' et ft M
Owner`s Name 0"661
Map/Parcel# 1034
Address 60 T Ve -A �u-� Q j
Lot#
Telephone# _* . q�Q —�C�00
Installer's Name �� o .er(�k tf—
Designer's Name��er IYI I
Address�kui
,,((,�, `L
Address�3 Je-T._1._t_ 13.
Telephone# p ; - (
Telephone# -
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) gpd Calculated design flow Design flow provided J36 gpd
Plan: Date Number of sheets _ Revision Date
Title
Description of Soil(s)'
Soil Evaluator Form No.. Name of Soil Evaluator Date ofEvaluation
e
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 agr es to no pla th/e� system in operation until a Certificate o Copipliance has been issued by the Board of Health.
Signed LVt �Vv� Date
Inspections
)qv
4 11 FEE
COMMONWEALTH OF MASSACHUSETTSlel' �
Board of Health, 01 MA.
,. 0
CERTIFICATE OF COMPLIANCE i�
Description -of Work: -QtIndividual Component(s)C)Complete System ��jj %' e511
The undersigned hereby'certify that the Sewage Disposal System; Constructed ( ), ReRaired ( ), UpgradedW, Abandoned ( )-
at ? C �' 1 kja,.
has been installed*ccoraai. e "th the pro��sio>as of 310 CMR 15.00 (Title 5) and the.ap roved design plans/as-built plans relating to
application No. dated' �%� Approved Design Flow- (gpd)
Installer 010`3f { r�.1cl Yl.W( I(A �—
Designer::�,UC.O-,P % 1'! Inspector: Date:
'The issuance of this permit shall not be _onstrued as a guarantee that tte system will function as designed.
No., i✓Ca yC , 6 `•-V t, p FEE _
' //,) COMMONWEALTH Of MASSACHUSETTS 11-7
Board of Health, 7 oun+ , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
is hereby granted to Construct( ) "Repair( ) Upgrade.A-) Abandon ( ) an individual sewage disposal system
as described in the application for
pSystem'-ConstructionJ f� ,�// r
Dis osal Permit No.�, dated
Provided: Construction shall be completed within three years of the date of this penxt` . All local conditions must be met.
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Form:1255t Rev. 5/96 A.M. Sulkin Co. Chadestown, MA: Date (� f � Board of Health ! '