HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6041DC- 9-442-q PL,P-M -20— COM -7
a8 3 COMMONWEALTH OF MASSACHUSET TIS
Board of Health, Y"AnAI MA,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
FEE' 6z� I �00
OCT 0 2 '410
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - 0 Complete System 0 Individual Components
Location Q
Owncr'sNamc __Y�,vv"j W(PlCCjt,%
Map/Parccl# H 'a
Address 'Z % S--V-,z 2�L% \—h
\1 t�.n S-
Lorif j5_ls I
Telephone#
MI -N- 6 z (za o
Installer's Nam fit
0
Designer's Name
Address V
Address
=TeleplioncM, I q 14 �' ' —) - tf __3 -C)MO
_5
Telephone#
Type of Building V
Dwelling -No. oFBedrooms
Other -Type of Building
Other FiXLIIrCS
Lot Size sq.
Garbage grinder(
No. of persons Showers Cafeteria
_e'
Design Flow (min. required) gpd Calculated design flow '330 Design flow provided 4- S gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) —
Soil Evaluator farm No
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
kj, _cs- QkL
of Evaluation 61Z
The undersi �_�,e ces, install die above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
., t of
C Stem
further agre s t ot t C system in operation until[ a Certificate of forrilimice has been issued by the Board of Health.
Signed Date 11-j & ) q
I I L
Inspections
01
Na. (3:0 1 14 �:iFEE "i
d
COMMONWEALTH OF MASSACHUSETTS
Board o f] AM.
GERTIFICA]FE OF COMPLIANCE
Description of Work: 0 Individual Component(s),Q,, 'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired O, Upgraded Abandoned
by:
has been installed in accordance with the 0 f 310 CMR 15.00 (Tide 5) and d1gj -built plans relating to
of
design ians/as
pip
application No. dated r? Approved Design Flow,, '14' (gpd)
tt A I
�'i N', Inspector: Date: 7�,'Designen �j V
The issuance of this permit shall not be construed as a guarantee that tfie sy'Stem will function as designed.
No:,)o fm�iFEE'- 16
P t �'n
9.1 COMMONWEALT-1-1 OF MASSACHUSETTS J- eo U_,
Board of Tlealllt, `7'- I MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( Upgrade( Abandon( )an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. JJ4%. dated i7-'/
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 6/96 A.M. Sulkin Co. ChalwoNn, MA Date fi1) Board of Health