HomeMy WebLinkAboutApp-Permit-Compliancet'al� 26-23 I r L i6rl3�J
Nn. �
PL3bx o WI\/ COMMONWEALTH OF MASSACHUSETTS
2i7Board tfHealth, � MA.
APPLICATION FO -11 DISPOSAL SYSTEM CONSTRUCTION PE MIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
Location eb,
Owner's Name ,j�p� v
Map/Parcel# Li�- �
Address
Lot#
Telephone#
Installer's Name,
Designer's Name
v G?
Address !�xv,
Address
Telephone# Z>6:- VZv — / L j s
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building
OtherFixtures
Design Flow (min. required)
Plan: Date
Title
Description of SOII(6)
Soil Evaluator Form No.
_ gpd Carculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agr s ' Mall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre o to la the system in operation until a Certificate of mpfiance has been issued by die Board of Health.
Signed Date /yl27 ' c- / / �.p
Inspections IIZ7I ��i. �1�� 1Y1S�1, 'IbT—fi'IS � �.`lal�le-bI/'Qle�—
No.
COMMONWEALTH OF MASSACHUSETTS „
I Board of Health, AJ d t-)"° , MA.
CERTIFICATE F COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaire y.5)Upgraded ( ), Abandoned ( )
by.e %ty 1) WA -z— C" c3/a:�`l ag)d ��0� -)
has been installed in accordance with the proviso ms of 310 CMR 15;00 (Tide 5) and the approved design plans/as-built plans relmi g'to
application No. '2"0 -1,7 t % ,dated (1 '?' � � U �? /� . Approved Design Flow (gpd)
Installer ' `S"C--&fr- C,., t` .. � m^`D'..:`.. J� - r
DesignerInspe"- Date: j a 0 2
� ;t
The issuance of this permit shall not be construed as a guarantee that t
' pt the system willTunction as designed.
No.
I•TC
COMMONWEALTH OF MASSACHUSETTS ('.A -
Board of Health, V4-y484W 0 U114- , MA.
DISPOSAL SYSTE CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(,,) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at a: . '.. /,@ as described in the application for
Disposal System Construction Periuit No. ` C'd( •) , dated
(-1
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Porn 1255 Rev. 5/96 N.M.9ulRln Co. Ctadesmvn,6�A Da[e] t �f fF'�l'e Board of Healtlir, ,� i�. ?�-[ !�e