HomeMy WebLinkAboutApp-Permit-ComplianceNo. 00 W YCA t -Q / J
COMNIONWI;A13I1 OF MASSACHUSETTS
BoardlfFlealth, �/Lemoo-n4 MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
FEC
REQ;
OCT UPON
Application for a Permit to Construct.( ) Rcpaim(ef Upgrade( ) Abandon( ) - ❑ Complete System 21odividual Components
Location
Owner's Name -_-
Map/Parcel# 4 -7 ....
Address
Loud
Telephone#
Installer's Nam C\,
Designer's Name
Address l\ �rJh� 2
Address
Telephone# f
hone#
Telep.11
Type of Building Lot Size sq. ft.
Dwelling -No. of Bedrooms a Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description ofSoil(s) _
Soil Evaluator Form No
_ gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date _
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS o\c.CJL -' \,� \t\ 11 1 U 13 to v>v w• \
y,A- k [,, D R�C,�_c .-� R I. St a
gpd
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 Compliance has been issued by the Board of Health.
Signed a� Date 161`"l1(I
Inspections
No.t� )�..�'"Q 76 C .L)Q �:>,r",
COMMONWEALTH OF MASSACHUSETTS FEEg.00
Board of Health, MA. �, )
CERTIFICATE OF COMPLIANCE
Description of Worlr. Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (Upgraded O, Abandoned O
by:
at
has been installed in accordance with the
application No. ) -03 , dated-
Installer
ated_Installer SL's 4 m, l v e,.€a
0 CMR 15.00 (Title 5) and the approved design plans/as built plans relating to
Approved Design Flow ` (gpd)
t
Designer: ""�`"'Inspector: ,✓'Z,.^;v. �•.ttfi�zA+".::st.: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
'C-3w.?,..+,)f�g
No. "a CC FTE
COMYIONWEALT14 OF MASSACHUSETTS
Board ofHealtlbMA. k @I
DISPOSAL SYSTEM CONSTRUCTION PERMIT( � lt„I ((,1
Permission is hereby granted to; Construct( ) Repair(v"j Upgrade( ) Abandon ( ) an individual sewage disposal system
at WO ten Mf -r r \_ C,
Disposal System Construction
CO , dated
_ as described in the application for
Provided: Construction shall be completed within iree years of the date of thi�perynit. All local conditions must be met.
Form 1255 Rev. 5199 P.M. SWIM Co. Ctmlolwn, MA Date df`'r'Jr BoardofHealth ,r)4.!
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