HomeMy WebLinkAboutApp-Permit-ComplianceNo � r FEE ____��✓ � [LLJ
10 COMMONWEAL OF MASSACHUSETTS
Board vfHealth, ARMOUTM I�EALTH Dom, �^�'�1'�G
6 ROUTE
APPLICATION F'OR ���� UCTI®N PERM1T
ppi cation for a Permit to Construct( ) Repair( ) Upgrade) Abandon() - Complete System U Individual Components
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Owner's Name L
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Map/Parcel#
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Address T
Lot# /17Z
Telephone#
Installer's Name /
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Designer's Name
.Address// 7tv+i�+
Address G�2 5
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Telephone# SZO
d13 Z— —ZV7-S
Telephone# ,&25g 36-Z —
Type of Building /�'�5/G/e "C _ Lot Size /Zi ��d sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons �— Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ?56> gpd Calculated design flow � Design flow provided gpd
Plan: Date Number of sheets ` Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordancemith the provisions of TITLE 5 and
further agr o not t place the system in operation until a Certificate of Compli ce has been issued by the Board of Health.
Signed Date / Z Z % 2d/,
Inspections
No. ({ Z5 FEE 3 U
COMMONWEALTH Of MASSAC14USET
Board of Health, S`G'T `^ , MA.
1�� �T
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CERTIFICATE Of COMPLIANCE �.`
Description of Work: U Individual Component(s) 90 Complete System
The und�evsignedd hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded), Abandoned ( )
by:
at __L7 /'n
has been installed in accordance with the provisions of 3 0 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application,N`o.r -3 , dated �•Z — Approved Design Flow _3f(gpd)
Installer
Designer. Inspector:.
The issuance of this permit shall not be construed as a guarai
Date:
the system will function as designed.
No. - ._ COMMONWEALTH
�T�}�jE_. �(.~ {`�g� j �( FEE
'l,OMMOl� V'1' LTH Ojt' SS1�'L_,I-7t�1 SETTS
Board of Health, �T ! , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(: ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three.years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health