HomeMy WebLinkAboutApp-Permit-ComplianceNo. O YC.—C 0-2-- UZ. FEE
20 --0 --51 COMMONWEALTH OF MASSACHUSETTS CIS Z
Board of Health, Ii112 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairs/) Upgrade( ) Abandon( ) - ❑ Complete System EI'lndividual Components
Location
J j- –cw 5
Owner's Name Q n
Map/Parcel#
1
Address
Lot#
Telephone#
Installer's Name
5L
Designer's Name
Address `
Address
Telephone#
" b
Telephone#
Type of Building
Dwelling -No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
gpd Calculated design flow
Number of sheets __.
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
r
Design flow provided gpd
Revision Date
Date of Evaluation
00
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t,2not to place the system in operation until a Certificate of Com Bance has been issued by the Board of Health.
Signed Date i 0
Inspections
No. C.»,✓ 1°"4 �"X^ w,:� C"l " - r)%o v«�. FEE vu `. 5" ✓o
COMMONWEALTH OF MASSACHUSETTS gym.
Board of Health, PIVTW(ilYGMA,
CERTIFICATE OF COMPLIANCE.
.E
Description of Work: ❑ Individual Components) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (4, Upgraded ( ), Abandoned ( )
at S i n
has been installe44n)ad
ccordarace with the proLisiotis of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ('' > dated °'�' I j rr (1l.Approved Design Flow
1 {—(gpd)
Installer
Designer: Inspector:
m.....yµm.w»a u
�� k h.. �e�(i"• Er(-,. �„? ..� �,...__.. Date: f
F � r
The issuance of this permit shall not be construed as a guarantee that die systern willfunction as designed.
No. Uwl7ot•4 t%l:. "2-U ^ 2.-7a d7 5( p, l.,. �;.".ir:�-r''s•P".s �,^---' FEE •.2T'�)Q'
COMMONWEALTH OF MASSACHUSETTS � It-� '°�
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(-') Upgrade( ) Abandon( ) an individual sewage disposal system
at t i e MV! i) 4 C. L--) f'�,i fr "' r as described in the application for
Disposal System Construction Permit No. i - P , dated 4 0
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkln Co, Chetegme,,MA Date °2� f f,,.E1 Board of Health(-""�