HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE 5, 5, 00
COMMONWEALTH Of MASSACHUSETTS
Board of Health, AR—mo U Ted , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(VIO"Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
Location 2S O 8 i UN P16 --K 94
Owner's Namedznd S e—r
Map/Parcel# JO/ 173
Address /O S J , Z'i e, --n "tj)Get T
Lot#
Telephone# o f- 1. Ll 19 q
Installer's Name )% heer J3, wr-o -'n L >
Designer's Name
Address 216ra4wes
Address
Telephone# (-S-G81-(5-0q- 2-6-38
Telephone#
Type of Building ISPs i i je-k% 1—+ -GL ( Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
DESCRIPTION/ OF REPAIRS OR ALTERATIONS
T � 14'X t; f led&k 16 1 T
Name of Soil Evaluator Date of Evaluation
V 4 e
Cif- 1l:"OVL R uSe A(
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 pla e}'}j(,e tsy-stern in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed W AV N A—K—K -X4`6- Date '-/-123-/,�-
COMMONWEALT14 Of MASSACHUSETTS" .� /� FEE �
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (,I,,Upgraded (_), Abandoned ( )
at � D�tr r
-moi
L
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. dated . Approved Design Flow ----,(gpd)
Installer
Designer: - - Inspector: Date: ->-/_
The issuance of this permit shall not be construed as a guararitepA the system wiu ction as designed.
No. (.._� FEE
J
COMMONWEALTH Of MASSACHUSETTS
Board of Health, yA
DISPOSAL SYSTEM CONSTRUCTION PERMIT 4 6G CC
Permission is hereby granted to; Construct( ) Repair( ,y Upgrade ( ) Abandon ( ) an indi�iidu�al�sewage disposal sy tem
at 1 .. Q _ _ s, A ! v as described in the application for
e
Disposal System Construction Permit No: , dated / Y�
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�i-�
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