HomeMy WebLinkAboutApp-Pemit-ComplianceNo. �,�--2-o-Co3311 FEE
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)CI - CONI MONWEALTI-I OF Ali ASSAC14 JSETTS
Board r f flecdth, 'YAP -840011+ , MA.
APPLICATION FOR DISPOSAL SYSTEM, CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System O Individual Components
locationU
Owner's Name
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Map/Parcel#
Address 16
Lot#
as described in the application for
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Installer's Name
Desig'ner's Name
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Address �%� J
Address �""
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Telephone# ,_ �`r'
Telephone#
Type of BuildingLot Size sq, ft.
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Dwelling - No. of Bedrooms '_T,, Garbage grinder,(
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixurres
Design Flow (min. required) gpd Calculated design flow Design flow Provided _17b gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. `" Name of Soil Evaluator Date of Evaluation
DESCRIPTION OFREPAIR,SORAITERATIONS 11
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further apxes to not to place the system in operraa%on until a Certificate of Compliance has been issued by the Board of Health.
Signed`f=l�/l� /,i �/ " Date
brspect:ions ZV 20 o il t c Oy7,5�--
No ) -'E.IkM(..`.it_(^i 12tli FEE 4,'�-.�''i (y)
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA, tjt
CERTIFICATE OF COMPLIANCE I; Jl "" 1
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Description of Work: Cl IndividualComponent(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired O, Upgraded O, Abandoned ( )
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at , .�=i' t ! ::.��-� _a ,� toe 'Al v...*P / s`'v ' .t ,x. i r
has been installed in accordance with the provisions of 310 CMR 15.00"(Title 5) and the approved design plans/as-built plans relating to
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application. No A/, r„`� dated �? °R'�.,?�r 4 v° Approved Design Flow 0L^ (gpd)
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Installer f`l'441,4"'"1 . -
Designer:_vv,�s,��.::°_� �''.,"w1a+= Inspectort. T"t weal...,"t1.frC_... Date: 717,/L-20 ..
The issuance of this permiVshall not be construed as a.guaramce thaf'the system wilt -function as designed.
No. �A 1 ^��%ia'. �( � P:� C A`tA5A7
101, COMMONWEALTH Of MASSAC14 JS -EFTS
Board ofHealth, �1'`-P-LOBt�f�`�' ,MA.
DISPOSAL SYSTEM 'CONSTRUCTION PERMIT
FEE J%a. �»!r)
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Permission is hereby granted to; Construct(
) Repair( )
Upgrade( ) Abandon(
) an individual sewage disposal system
f
at ' rTP
as described in the application for
Disposal System Construction Permit No. P' cn� 95d, , dated
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. Sulkln Co. ChadeoeR MA Datell'), I ; k.... ? Board of Health %_1 R'R