HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE �� �-" i '��/�,:. FEE e:_e
COMMONWEALM Of MASSACHUSETTS 046--od
YApMfuTM HEALTH DEBT. s l
Board of Health '
,, onto , MA.
. SP LI ATI®N FOR DISP N'' MM f UCTI®N PERMIT '
lication for a ermit to Consfruct( ) Repair( ) Upgrade( Abandon( - ❑ Complete System 1&dividual Components
L. }
ocation Gip
7
Owner's Name
1 ap/Parcel# -% 7
i _$ <,/
Address _�� e -
Lot# �� J-
Telephone#
Installer's Name
U� {
Designer's Name
Address/
Address.: -'k,,,
Telephone# `j
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Lot Size 31;r y .t d sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 1A gpd Calculated design flow Design flow provided � gpd
Plan: Date Number of sheets /' Revision Date I&P
Title
Description ofSoil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS j -�cs,7..0�� y ` 1 G/'� G a.r- 7•o cc7
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 to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
`
,-.Signed Date
Inspections 6 -
No. S/ - -- r—
lC-
�_V1y1NI®NWLftI,TII Uk IVINKALHUSATTS � , z
Board of Health, y/J/f/�io r rs' , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: �Kndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ),Repaired (u), Upgraded( ), Abandoned ( )
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.,>Z Sdated - 2 Approved Design Flow ii i _.:(gpd)
Installer
Designer: Z:!z Inspector:_ / f Date:''
The issuance of this permit shall not be construed as a guarantee th, the system will function as designed.
No. % . , �" C ''�(/I /`��1/" FEE
COMMONWEALTH Of MASSACHUSETTS -3 >;,
Board of Health, �/���! e �7 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (_/) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at G eet. /Z/J as described in the application for
Disposal System Construction Permit No. /r� �, dated 7—
t
Provided: Construction shall be completed within oe date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChadeMown, MA/! Date % _-'_ �' Board of Health / �
'14,1111 P � cl .e �, . 7L. / Iwo. "EAd-A Ci _ �l _ , / C,/W —7-F7 .,. 5 Z ��`/-lD/7 c'—