HomeMy WebLinkAboutApp-Permit-ComplianceNo. `W L— Z O. 39ti-1
D -P ox' ON I_Y COMMONWEALTH OF MASSACHUSETTS
BoardofHealth, YAl1MOttld MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIONN"
Application for a Permit to Construct( ) Repair (wUpgrade( ) Abandon( ) - 0 '&/I,Complete System 1n
FEE 55
U#11 oZ-
U 3 2020
EMM -119
Location '
�, s: • Owner's Name G• z ��C.
Map/Parcel# C)L, v)
'nq'
Address J)U�/�OctJdq,� oa6o%
Lot# J 5_3
Telephone# ^22V_
Installer's Namec'PUO
fVG ��C Designer's Name ,u
Address yj —
5 per„' Address
Telephone# r
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
The undersigned
further agrees t
Signed
Inspections
the above
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
I tsposal System in accordance with the provisions of TITLE 5 and
until a Certificate of Com Iry has been issued by the Board of Health.
Dam 3 I
No iC"v "7i. vv, FEE t r ...
COMMONWEALTH Of MASSACHUSETTS 4> V.� �
Board of Health, \/A-0\4 () IT)l MA.
CERTIFICATE OF COMPLIANCE
Description of Work: OIndividual Component(s) ❑ Complete System
The undersigned hereby. certify that the Sewage Disposal System; Constructed ( ), Repaired O, Upgraded O, Abandoned ( )
by: •c,
at
has been installed to accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. (lr.: d dated l t f ( Approved Design Flow (gpd)
Installer
Designer: Inspector -.,Date: t`
The issuance of this permit shall not be construed as a guarantee thaLthe system'wll function as designed. P
t'c0 \Ys..a't_"y"u.-.� ... .,. v FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, X 12 t (jt rspa- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
oryL-y
Permission is hereby granted to; Construct( ) Repair( `,) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
Disposal System Construction Permit No. ( r ,dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this.permit. All local conditions trust be met.
.i '
"
Form 1255 Rev. 5196 A.M. Sulkin Co. ChaLgon, MA Date '� (""Board of Health `