HomeMy WebLinkAboutApp-Permit-ComplianceNo. VC—"tU'-"cl [J �].� �J t K--"[9 _002_ / cl3 FEE
C MMONWLALTII OF MASSACHUSETTS Glz�j1256
d✓F'✓ lrva % '` � Borud of Health, yf3?Z/1 OU I1'} IWA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
f j, A plicuimi for a Permit to Construct( ) Repair( ) Upgracle( AbandonO - Jd Implete System ❑ Individual Components
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ocation
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Owner's Name
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Address
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Telephone#
Installer's Name
Designer's Name
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Address
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ddress
Telephonedk �`"°'
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Telephone#
Type of Building i I.ot Size sq. ft.
Dwelling -No. of BedroomsLk /'t,/ /G�i -3 l Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other rixtures
Design Flow/ (min. required) gpd Calculated design flow. '"7 Design flow provided _gpd
Plan: Date" �j_21119 Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
OF REPAIRS Og.RALT TIONS
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Date of Evaluation
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The undersigned agrees to install the above described Individual Selvage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to cc the system i operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
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No.
C®MMOWRI'I1 OF MASSACHUSETTS'
1.
Board ofl allh, NIA.
CERTIFICATE OF C®MPLIANCF
Description of Work: ❑ Individual Component(s) O'tomplete System
The undersigned hereby certify that the Selvage Disposal System; Constructed ( ), Repaired ( ), Upgraded (t/j, Abandoned ( )
at S .f " , 4 ,.. , d +,✓. �`" ¢ ;-'s•• i? 6i i�/)t ,) i3-•-1
has been installed in accotda ce.with the provisions of310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No ) n ' Ip '"{ dated /t/ ",6 - f Approved Design Plow A d' ) (gpd)
Installer ".l v"
Designer:."', €€ s"�(s al w3:t .-. Inspector: ;� t °.P,+ ^' is`°".,� Date:
The issuance of this permit shall not be construed a; a guarantee that the system will function as designed.
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COMMONWFALTli OF MASSACHUSETTS
Board of Health, '//') RAI (AN , MA.
DISPOSAL SYSTI.M CONSTRUCTION PERMIT
Permission is hereby gran ted to; Construct( ) Repair( ) Upgrade(,) Abandon( )an individual sewage disposal system
at 9A% ( ry h�. `'�? 1 E i' .i a �i °` ;v I- as described in the application for
Disposal System Construction Permit No. .1- .�''4. /1 , dated .' "` O
Provided: Construction shall be completed within three`Ve(ats of the date of this perpPt All local conditions must be met.
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Form 1255 Rev. 5196 A.M.SUIkIn Co. Chafre51mv0,M1W Date "`1Board of Health '4; ' i P f
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