HomeMy WebLinkAboutApp-Permit-ComplianceNo. $�L)C4 -6yS?0
COMMONWEALTH OF MASSACHUSETTS
Board of Health, y ifM0 to _i+ MA.
APPLICATION.FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct air( ) Upgrade( ) Abandon( ) - ❑ Complete System E] Individual Components
Location
Owner's Name f/1 y'GL
Map/Parcel#
�+
ji 3
Address (�
Lo.t#
Telephone#
Installer's NamexyjrV^
� cc L Designer's Name
Address
[address
Telephone#
—
(0 S- Telephone#
Type of Building t��J _ _ hot Size sq. ft.
Dwelling -No. of Bedrooms Garbage grinder, ( )
Other -Type of Building No, ofpersons Showers (), Cafeteria. ( ).
Other Fixtures.
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan:' Date Numbed• of sheets _ Revision Date
Title
Description of $oil('s)'.
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersiened.agrees to install the abov`PAescribecj Individual Sewage;Disposal System in accordance with the provisions. of TITLE 5 and
further agreeoplace to 2e.m eration until a Certificate of Compliance has been issued by the Board of Health.
Signed, Date _ O Aupff
Inspections.
No. 6 qs l
COMMONWEALTH OF MASSACHUSETTS FEZ j632�-
Board of Health, YOM4 MA.
,
CERTIFICATE Of COMPLIAINICE f . l o e C-
Description of Work: U Individual Component(s) U Complete System �-
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ); Repaired ( -- , Upgraded ( ), Abandoned )
k. JOA
at 1 • i �,k
has been installed in accordance with the provsio ]s of 310 GMR 15.00 (Title 5) and the :approved; design plans/as-built plans relating to
application No, f �i �-� � dated 1 55 . Approved Design Flow `"` (gpd)
Installer T� A t S PQM r,��f_ty
Designer: „""'"" Inspector: �l� C.3—f \ Date.: �„/�4^f
The issuance of this permit shall not be construed as a guarantee that the system: will function as designed.
No. i FEE' .
COMMONWEALTH OF MASSACHUSETTS
Board of Health, O V n+ , MA. l I�► e
DISPOSAL SYSTEM CONSTRUCTION REKNIT
Permission is hereby granted to; Construct( ) Repair(.. 'r Upgrade( ) Abandon( ) an individual sewage disposal system
(: V
at .}� `' -� as described in the application. for
Disposal System Construction Permit No: ECt' -0',00 , dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be- met.
jam✓ (%V1
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChadeOwn,h% Date "' Pinard of Health (%