HomeMy WebLinkAboutApp-Permit-Compliance11 �1,4.5LM-zo-bOl677 Samoa
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No. FEE
�ct- ®, t C®A'><Y 8NWEA1111 OF MASSACHUSETTS
Board tfHealth,� /�AMon+ , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct.( ) Repair( ) Upgrade(/Abandon( ) - ❑ Complete System ❑ Individual Components
Location
T
Owner's Name
Map/Parcel#
Address,t-
Lot#
Telephone#
Installer's Name
O 1 C .
Ser'
Na ✓� -
Address
''17S
N `
Address
Telephone#
— _
Telephonetlt —
Type of Building T I l. -
Dwelling - No. of Bedrooms
Other -Type of Building _
OtherFixtures
Design
Plan: 1
Title '
Lot Size
No. of persons
—gpd Calculated design flow Design flow
Number of sheets l Revision Date
ki l 0 i 0 sq. £t.
_ Garbage grinder 4/4'
Showers ( ), Cafeteria ( )
Description ofSoil (s) J1
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation CA 'A 1 ��
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t1 the stem' operation until a Certificate of om ancg has been issued by the Board of Health.
• Signed: Date C1
R r
Inspections
No. @:.% 4'7 �,.. w 9 VG:>4. CCl f i..2 (. )
e_ 'w COMMONWEALTH OF MASSACHUSETTS
F
i! -t Board ofFfenllh,
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Componen(s) ❑ Complete System f F
The undersigned lTrcby certify that the Sewage Disposal System; Cousnvcted ( ), Repaired ( ), Upgraded N, Abandoned ( )
by;..._1-'>t` < ! t IV ! Yl. V - ' 1 Jd /_ `., ' t
at y -,.-.Ga- ..t 1 �"` f3,_ fl ..:_�r.7 1. �,. (7 (~T
has been installed in accordance w�pith Ure provisions of 310 CMR 15.00 (Title 5) and thI d design plans/as-built plans relating to
applicationNo. %"14' .., °;'•`ilta[edd" Ap roved Design Flow~''^i (gpd) -�,"
Instiller S:>� 01" ) 11,� `ACIA _�r � I-� � �(� ��9��� 7 W CIL- � `1 k"Ic a t kie-1 "
Designer' 1C_C t' 4sf#_xttr- ^„QC IM -4 Date:
� T i
The issuance of this permit shall not be construed as a guarantee that the system will function as desiynted.
No.L^�'0`'"�`m )�,✓-0 d-9 ,... FEE
COMMON ALTH OF MASSACHUSETTS
Board of Health, p �r`FV2, FW01 g F MA.
DISPOSAL SYSTEM CONSTRUCTION I�ERMIT
3
Permission is herebygramed to; Construct( ) Repair( ) Upgrade (,ts)!!J Abandon( ) an individual sewage disposal system
at
as described in the application for
a,.
Disposal System Construction Permit No. /9-0,30, dated ✓. > r
Provided: Construction shall be completed within three years of the date of tlfis pens�rt ill l cal conditi�6tis mus[ be met.
f
Form 1255 Rev. 5196 A.M. Sulkin Co. CWeeme,hik Date /?.ti t�•Board of Health E w.�LW�-• ~�