HomeMy WebLinkAboutApp-Permit-ComplianceNo, f(&D C,2 -046t38 � L'�'(,(? 2�'"(�0 6 FEEbZl
a0 --oo`/ COMMONWEALTH OF MASSACHUSETTS d41633%
Board tfHealth, 7 L00T7+ MA.
APPLICATION FOR DISPOSAL SYSTEM,, CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repaire Upgrade( ) Abandon( ) - ❑ Complete System 3'Individual Components
Location
(,tJ, Owncr's Namc --
Map/Parcel# JY (Q
Address kt0 ( Df,
Lot#
Telephone# tyle_ ,,'q/- !J�?+�•
Installer's Namep)o4v(n(113n4yl'
"- C Designer's Name6sL
Address '1314 J1, r fAAA
7 Address 3v96Sr.iY V,rk.E-D t-
Telephone# e
C�
Telephone# ,�v�• +� ^ �qJ!
Type of Building
Dwelling -No. of Bedroc
Other -Type of Building
No. of persons
Lott Size n 860 sq. ft.
Garbage grinder
Showers ( ), Cafeteria ( )
Other Fisnu'es
Design Flow (min. required) 13.0 gpd Calculated design flow Design flow provided gpd
Plan: Date Number ofshects_ Revision Date
Title ow JANe x
Description of Soi s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to installth� ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place t�e system in operation until a Certificate of Compliance has been issued by die Board of Health.
Signed // i Date
Y '
Inspections
No ':�i V; i ti £ �.f:e-.� , ,.'�;:7 FCL
COMMONWEALTH OF MASSACHUSETTS
Board of Health, V/t)-ehi fJk./r MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Cl Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ('), Upgraded,(;;'), Abandoned ( )
by:
has been installed in accordance with file provisions of 310 CMR 15.00 ('title 5) and the approved design plans/as-built plans relating to
application No • dated'• e` ' Approved Design Flow - (gpd)
t e�
Installer • ` n ..t l.,
Designer: Inspector: 16V-tA*1 7EKGACIIQN� i�'W; Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as desibmed. %L'
No, t•'€S ti t1£, (,-C}-'t..ct .,; ( ,A li,t # }„i,.....
COMMONWEALTH OF MASSACHUSETTS
Board of Health, .” n 1,2 -j -.MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair,(V,") Upgrade�. Abandon(
at 'f 4.9£ fi °Fs ``. (^` rs r ` t,6 .f+J°41
Disposal System Construction Permit No:,�< . ,rk�" " dated a F1'2 n
Provided: Construction shall be completed within three years of the date of thispern
I i I r
Form 1255 Rev, 5/96 A.M. SuIAIn Co. ChetlesRRMA Date
2A wrsP.
J
an individual 5
as described
.cation for