HomeMy WebLinkAboutApp-Permit-Compliance:No.' -
No) C-Iq- Vq 14 4:�>qofi4
11---11- COMMONWEALTH OF MASSACHUSETTS
FEE SS.OD
cW 11%473
Board of Health, )6W,=Mll l H , MA.
APPLICATION FOR DISPOS7Abn
STEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(donO ❑ Complete System ❑ Individual Components
Type of Building' !/ Lot $ e sq. ft.
Dwelling -No. of Bedrooms S S Garbage grinder ( )
Other- Type of Building No. of persons Showers O, Cafeteria.
Other Fixtures
Design Flow (mi . re u r �d) gpd Calculated design flow Design flow proviiddped�^' 1 � gpd
Plan:' , .Z Ntylnber of sheets Revision Date 1 `` L
Title 1A!V uJLA,,jL.) C_,V1.V1-Y 3 U,'Y1 V
Description of Soil (s)
Soil Evaluator Form No. Name, of Soil Evaluator
The
Signed,
ORAL TERATIONS
to stall the above 4scribed Individual Sewage:Disposal System in accordance with the provisions. of TITLE 5 and;
p the tem er do until a Certificate of Copp*oche has been issued by the Board of Health.
Date Yh3/
p,, E } I,, �y p�
No. 1—tri{t� � L V FEE •�, 0
COMMONWEALTH OF' MASSACII SETTS
Board of Health; MA.
CEIPTIL'IC TE OF COMPLI 1 TCS 3 ,
Description of Work: El Individual Components) Complete System "' 4"3f
The undersigned her by certify hat th ewateDisposal System" Constructed ( ):, Repaired ( ), Upgraded ,� Abandoned ( ),
by - �+ .
at�,
has been installed_ip accordance with the rotrisi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to.
application No. dated `p roved Design Flow11 1110
(gpd)
CADInstaller •.,
Designer: Inspector: Date: _
The issuance of this. permit shall not be construed as a guarantee that the system will function _as :designed. _
V1.
No.,boa C "` -9 —0.1 ! ' F I' ` FEE i 5 . Q 0
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YA emoc m+ .111M.
5XI
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repair( ) Upgrade(�Abandon ( ) an individual sewage disposal system
at urV LAIAN'S14. S. N as described in the application for
Disposal System Construction Permit No. '1 , dated.+
Provided: Construction shall be completed thin three years of the date of this permit. All local conditions must be met.
Form 1255 Rev, 5196 A.M.Sulkin. Co. ChadWown, MA Date"i lip , Board of Health
II
t
711L t►: `ti. s s em' I
Addressr►��iiJOB
OF
Type of Building' !/ Lot $ e sq. ft.
Dwelling -No. of Bedrooms S S Garbage grinder ( )
Other- Type of Building No. of persons Showers O, Cafeteria.
Other Fixtures
Design Flow (mi . re u r �d) gpd Calculated design flow Design flow proviiddped�^' 1 � gpd
Plan:' , .Z Ntylnber of sheets Revision Date 1 `` L
Title 1A!V uJLA,,jL.) C_,V1.V1-Y 3 U,'Y1 V
Description of Soil (s)
Soil Evaluator Form No. Name, of Soil Evaluator
The
Signed,
ORAL TERATIONS
to stall the above 4scribed Individual Sewage:Disposal System in accordance with the provisions. of TITLE 5 and;
p the tem er do until a Certificate of Copp*oche has been issued by the Board of Health.
Date Yh3/
p,, E } I,, �y p�
No. 1—tri{t� � L V FEE •�, 0
COMMONWEALTH OF' MASSACII SETTS
Board of Health; MA.
CEIPTIL'IC TE OF COMPLI 1 TCS 3 ,
Description of Work: El Individual Components) Complete System "' 4"3f
The undersigned her by certify hat th ewateDisposal System" Constructed ( ):, Repaired ( ), Upgraded ,� Abandoned ( ),
by - �+ .
at�,
has been installed_ip accordance with the rotrisi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to.
application No. dated `p roved Design Flow11 1110
(gpd)
CADInstaller •.,
Designer: Inspector: Date: _
The issuance of this. permit shall not be construed as a guarantee that the system will function _as :designed. _
V1.
No.,boa C "` -9 —0.1 ! ' F I' ` FEE i 5 . Q 0
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YA emoc m+ .111M.
5XI
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repair( ) Upgrade(�Abandon ( ) an individual sewage disposal system
at urV LAIAN'S14. S. N as described in the application for
Disposal System Construction Permit No. '1 , dated.+
Provided: Construction shall be completed thin three years of the date of this permit. All local conditions must be met.
Form 1255 Rev, 5196 A.M.Sulkin. Co. ChadWown, MA Date"i lip , Board of Health
II