HomeMy WebLinkAboutApp-Permit-ComplianceT �b � c -t �63 gL.Oc 1q , DD
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COMMONWEALTH OF MASSACHUSETTS 03q55
�j,�j j�i rird e f Health, �'
MA.
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aT-APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to .Construct( ) Repair( ) Upgrade( ) Abandon( - li Complete System 0 individual Components
Location
Owner's Nam d C%/
Map/Parcel#
Address ' l
Lot# /
Telephone#
Installer's Name /G�)1 .5 t --- :
Designer'sName 'kAJ2
Address ��(X
Address12, AU ntx
Telephone#T - - .�---
Type of Building' _ Lot Size 1 t 2v -1 -sq. ft:.
Dwelling - No. of Bedrooms / Fit: Garbage grinder (
Otlier - Type of Building No. of persons Showers (' ), Cafeteria
Other Fixtures
Design Flow ( in. required) gpd Calculated design flow Design flow provided gpd
Plan:' Date / / Number of sheets —� Revision Date
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 agrees to not to place the system in operation until a Certificate of Compiian a has been issued by the Board of Health.
Signed.
�Date A
Inspections
No.11�q FEE it i . 0i�
COMMONWEALT14 Of MASSACHUSETTS1.2 IF CC 3 41
Eoard o f Health; T • t L.�/� (t ! , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) � Complete System
The tit : dersigned hereby certify that the Sewage Disposal Systernz Constructed ( ); Repaired ( ), Upgraded Xbanddned
by:
at
has been Iinstalled i accor;d e with the roVIsiions of 10 CMR 15.00 (Title 5) and t e roved design plans/as-built plans relating to
application No, l / dated, ^"/ r� Approved Design Flow " (gpd)
InstalleOLf) A 5 k� A 04 y'; .< 4 1 0.1
_
Designer 1 (4< 4-4-t- I t Ct�e L4 -11)A,.1, � /r� P✓Inspector: ' Date: _ f "ice
The issuance of this permit shall not be construed as a tee ,that the system. willfunction as designed.
No. i i� C a moi_" :+b' � t� E %� ;a,% C -W'i`ll tQ(;,:1'—
% COMMONW LTH Of, MASSACHUSETTS
Board of Health,V' ` ( ` ( �
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE' C)^
q!s
Permission is, ereby granted to; Constru�t0}-•-Repair( ) Upgrade( ) Abandon (` ) an individual, sewage disposal system
at )d V17J, '. :r !V `� A as described in the application for
Disposal System Construction Permit No. �' , dated
Provided: Construction shall be completed withfiiahcuoc4xs of ee date of this peAll.local con' 'tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkln Co. Chadestown,.MA DaBoard of Health