HomeMy WebLinkAboutApp-Permit-ComplianceV -p4 f COMMONWEALTH OF MASSAC14USETTS
Board of Health,*�� MA.
APPLICATION FOP. DISPOSAL SYSTEM CONSTRUCTI®N
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - O Complete System
FEE X(45 7 6
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Location 400wj2d
Owner's Name
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Map/Parcel# I
Address
loo Coo k,d
Pi ad
Lot#
Telephone#
Installer's Name C�- D( /�C
Designer's Name
Address rd e0'X :72
Address U
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Telephone#
Telephone# 150
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Type of Building 0,es C1-G%i i/al _ Lot Size -� UCXQq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) /(.� gpd Calculated design flow 7^3 0 Design flow provided 4/ �' gpd
Plan: Date lr�(.7 Number of sheets i I Revision Date r'' att-
Title
Description of Soil s)q� ✓c_ C k S s�tJrt^ oto Mrd,'V-, ) Id
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS — S6/u"'e t)OV"12 C 6bll s IrlJ7Tif/ 64/C'
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 _! 4c&) �'_��
Inspections �tt9 (% u l w-dLey 41611 /.C)
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COMMONWEALTH ®F MASSACHUSETTS 5
Board of Health, MAa t
CERTIFICATE OF COMPLIANCE ¢
Description of Work:,.,.GTndividual Component(s) E2Complete System AllThe undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired`( );Upgraded ( ),Abandoned ( )
at P'`tt)
has been installed in accordance widIIthe provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No ' (` (' ` 4 dated . Approved Design Flow �° � °)�') (gpd)
Installer V, ,o (.w.:qK,�.,�
Designer: _ 60 E� 4 Inspector: ` r• Date:
The issuance of this permit shall not be construed as a guarantee that the system willfunction as designed.
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COMMONWEALTH OF MASSACHUSETTS ckA, i&?
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Board of Health, 'V Nl"14�'` 0J I -° , MA.
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( ) Repair(i Upgrade( ) Abandon( ) an individual sewage disposal system
at2 as described in the application for
Disposal System Construction Permit No. �) µ iJ`n , dated
Provided: Construction shall be completed within three years of the date of this permitgAll local conditions must be met.
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Board of Healthy ' i
Form 1255 Rev. 5/96 A.M. Sultrin Co, ChsteMarh MA Dale '