HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6641D-L9--o0NS FEE i6z;:00
lq J%
COMMONWFALTII OF MASSACHUSETTS Cfb�266_7
Board (?f Health, 0 MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - CI Complete System D Individual Components
Location //
Type
uA 3 �.ee l'
Owner's Name �q y�l- c %d7••
Map/Parcel#
(0"?
Address
Lot#
Telephonetk
Installer's Nam
Designer's Name
Address 3
/ S,f,
Address
Telephone#,%,8,-
7767--
75_
Type of Building tw& .,* Te /0 r¢vse %y Lot Size sq. ft.
Dwelling -No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
_gpd Calculated design flow
Ntunber of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow provided
Revision Date _
Date of Evaluation
gpd
Ki( -etJ
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of to place the system in operation until a Certificate of Compliance has been issued by the Board of health.
Signed �' Date-1110zl
Inspections
No l"',1 !.4 (�i" ��1 "f,�'),f �.J - FCL
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Vhy, 1N)T h1-
CrRi IFICATE OF COMPLIANCE;""t /s f e ,•
Description of Work: C(Individual Component(s) 0 Complete System
The undersigned hereby certify that (lie Sewage Disposal System; Constructed ( ), Repaired ('f`)Y, Upgraded ( ), Abandoned ( )
at
has been installed in accordance with the provisions, of 310 CMR 15.00 (Tide, 5) and the approved design plans/as-built plans relating to
application No ' t" ,dated : < o - Approved Design Flow . -w'" (gpd)
Installer.✓.""�`"^`'"-
/ r ro
Designer::.""° Inspector: Date: ..•'�✓:�/i"�3 /,�
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 1"l,(a-!4)C-1 1 1)Cl`�`�;� cAer, <r a :aE.k'11t. C`a,i1t".- FEE
COMMONWEALTH Of MASSACHUSETTS
Board o Health, iP 4L,,'j()I n:4� MA.
DISPOSAL SYST:L'M CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(,/') Upgrade( ) Abandon( ) an individual sewage disposal system
at f as described in the application for
Disposal System Construction Permit No. f dated Z
f
Provided; Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Chaftoio, h'jA Date 'r y 4.a7i 1,? Board of Health