HomeMy WebLinkAboutApp-Permit-Compliance300c- 14
No. P Ay
MMMONW-VAITH ()F MACNACHITUM
Board of Health, Yum /)I Mj MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION FERMI]
FEE � 65�00
cjL+-3Y7(o-7
Application for a Permit to Construct( ) RepairN Upgrade( ) Abandon( ) - Q Complete System AIndividual Components
Location Lt5 C_,&jA)5
Owner's Name t)6"4cDSoVWOS7&�
F "-r�AjA-rA_5br_)
Map/Parcel#
Address P0 &K 45-00q3 NcLAS TK 75a(,�
Lot#
Telephone#
Installer's Name
E
Designer's Name
,Address�3
Address
Telephone# 502 -(4'71 -ft-77
Telephone#
Type of Building R_ GS I P&Q-1 I An L_ Lot Size
Dwelling - No. of Bedrooms
Other -Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Tide
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
— gpd Calculated design flow
Numb& of sheets
Name of Soil Evaluator
&PCA66- P -90)e
sq. ft.
Garbage grinder
Showers ( ), Cafeteria
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to p"o place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 3
Inspections
No. B00 -,00
12 - FEE
COMMONWEALTH OF MASSACHUSETTS 7(
f Health,
Board o Y&A 0 VM MA.
CERTIFICATE Of COMPLIANC
Description of Work: 4 Individual Component(s) Q Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired Upgraded Abandoned (
by: QAP&u.)ip& &xrEi&Pki_5i5S LLC
at 449 kiawk:j cpzkPAP
has been installe7fin a cKdM with fhe �ovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated 7 Approved Design Flow (gpd)
LLC T2.i La � 111 (,A P" I
Designer: Inspector: ,41 ( L/64/ MACZ Date: -or 7z(.
The issuance of this permit shall not be construed as a guaran(§e`that 'the system will function as designed.
7000G: 1 0 OQ J 0 0. 0-
0 0- 00 1) :;Cc 10 1__1 0. 1) C. C• 3Q I C11", 4J: Q C,
No. C-4 P a�1 -r) C tJT FEE 00
COMMONWEALTH Of MASSACHUSETTS � 41-- q7 G-7
Board of Health, AIA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(() Upgrade( ) Abandon( )an individual sewage disposal system
at P4 as described in the application for
Disposal System Construction Permit No. / lb — dated 7-
- /7911 e 9 (;-/
Provided: Construction shall be complVea within tbreey 's o4 —the date of this permit. All local conditions must be met.
.=
Form 1255 Rev. 5196 A.M. Sulkin Co. Chadestown, MA Date 127/� Board of Health