HomeMy WebLinkAboutApp-Permit-ComplianceNo. %,Dc " j6_ 1O5gq FEE �7
�6 - 74 CONI MONWEALT14 Of MASSACHUSETTS
—006764 _
Board of Health,��0V I e , MA.
-APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( -omplete System ❑ Individual Components
Location a
Owner's Name
Map/Parcel#
Address
Lot# i
Telephone# _ �, _ 4 tk
Installer's lame C-✓ d St�fit7 J
Designer's Name. BEC
E �c,.j
AddressG v,Mo J��
Address L
Telephone# 7 7 9 P, YG - G ib)
Telephone# SU7771
Type of Building X r51, C&), 4 j 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) 3 3 Q gpd Calculated design flow �Design flow provided 33_ gpd
Plan: Date Number of sheets 1 Revision Date
Title
Description of Soil (s) e she /G>q S �.1 J — 131
17e^�Gwi ,
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTI^�/7
ONOF REPAIRS OR ALTERAT�IONS _71,0S,
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 Comb lianc has been issued by the Board of Health.
Signed Date 6
No. 0F1 ]Z� �L,—i��'}�j`19 S�SL J2
'l..®1°1lM®lY MVV' I~1"1�LT� OF MASSACHUSETTS 4 1312
Board of Health, lav MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) .Q -Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repairer [Jpgraded ), Abandoned ( )
by: i
at --�
has been installed in'a?c�r nce vvi tFu/�osic4ns of 310 CMR 15.00 (Title 5) and the Wproved design plans/as-built plans relating to
application No. dated — Approved Design Flow (gpd)
Installer i It rJ�` L+O? C P.✓I SiX �1 p 1
Designer: Inspector: :'�yd9a Date:
The issuance of this permit shall not be construed as a guar ee dat the system willfunction as designed.
COMMONWEALTH ALTH ®F MASSACHUSETTS
Board of Health, _T" MQ n:)+ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE t '
Permission is hereby granted to; Construct(, ) Repair," H- Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No./��/—���/��, dated.4--Z
Provided: Construction shall be co t let�rwithtn hl !I� of the date of this permit. All local conditions must be met.
Form 1255' Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Dat /� Board � eai th J