HomeMy WebLinkAboutApp-Permit-ComplianceNo. OWDc- M- Sro
- 2-0 - Ue 31x23COMMONWEALTII OF MASSACHUSETTS
FEE
Board oJHealtlt., YiiZkQ Tl -i , MA. [ ( � % 20
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PER IT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( 0 Complete System El Individual Components
Location 0 80Y 11)6c—
Owner's Name /
Map/Parcel#
Address ao l:, or,
Lot# 3
Telephone# 6
Installer's Name �-. Ike
Designer's Name UNNC �
AddressP6 66X '
Address 3 r
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size 6 LoS sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
n2�-,
Design Flow (min. required) 7:1(J gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS ORALTERATIONS
-,Y'a b 3,20
Name of Soil Evaluator
Date of Evaluation
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
Date
S. (^9„S FEE
Via. fl kr)
No. 4 6
COMMONWEALTH OF MASSACHUSETTS ,
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) 0 Complete System AA ,,h�od
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraaed'� (tt1, Abandoned ( )
bY
athas been installed in accordance with the provisions of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . Approved Design Flow (gpd)
Installer 1LV) ,/tNN
Designer:i?,!'S'.t,, 14bK
The issuance of this permit shall
g
ti
be construed as a guarantee
Date:
function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board tfHealth,�s��' MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE �,a ,"d`uk G, no
Permission is herebygranted to; Construct( ) Repair( ) Upgrade( -,4y Abandon( ) an individual sewage disposal system
at ar i ;`9 " E ( ! t' i t l �r`.tf (/P� 'r $ 1 ) _'A � ��} a,:y %4 as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
vo,m125e aeo.sres A.M.&ulkinCo. tldotmaMA Date f i I1 'ti Board ofHealthi— I