HomeMy WebLinkAboutApp-Permit-ComplianceNa. �II L�2b-�I339 R(� ,"'G.�J•�VV(��I FEE XD
COMMONWEALTH OF MASSACHUSETTS Lwu
BoardofHealth, y4e&d(r W MA.
12 2020
APPLICATI®N F®R DISPOSAL SYSTEM, CONSTRUCTI®NTH DEPT.Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑Iomponents
Location
Owner's Name
+ �S
Map/Parcel#
0
Address
Lot#
Telephone#
Installer's Name
Designer's Name�e
Address
Address t' G: f'
Telephone#
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Telephone# 3 S — `p C(
Type of Building rl('> t cuC 10,1 Lotsize `T" / J sq. R.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures /
Design Flow (min. required) (CUC-2' PCS gird Calculated design flow `3:3C) Design flow provided J 1(40 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No
Name of Soil Evaluator
Daze of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to nto fic,oyplace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed — l /—� Date _ "' D
Inspections C/
No. VW -2D -4,3347
i .EE FT�
COMMONWEALTH OF MASSACHUSETTS'pp� EE 36y
Board ofHeallh, YHI9MooD4 MA.
CERTIFICATE Of COMPLIANCE 2. �(e► °
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned ( )
by: ✓1
at
has been installed in accordance with the pr vs i ns of 310 CMR 15.00 (Title 5) and `th"e approved design plans/as-built plans relating to
application No. Z D U Lf dated Z Z�Approved Design Flow I_(gpd)
Installer
Designer: tz 1 Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function m designed.
Non'•�);ifEj,i —4 FEE.�',"'a
COMMONWEALTH Of MASSACHUSETTS ( T
Board of Health, )�A` 4'pvl O 0- - MA.U \
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( ) Repair(--.,) Upgrade(t,.)`s Abandon(
at
Disposal System Construction Permit No. dated
an individual sewage disposal system
_ as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Farm 1265 Rev. 6/96 A.M. 6ulkin Co. Chake9am, MA Date Y P t ? l f i Board of Healtll4 P Y.i�P k� _✓
_.