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HomeMy WebLinkAboutApp-Permit-Compliance0 7:yF'::zA ;9 No:' 064DC-f6-- 1034$ Pe? 1,?& Dix FEE 4'5'3. 00 COMMONWEALTH OF MASSACHUSETTS 3d q ► -7 Board of Health, APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT plication for a Permit to Construct( ) Repair(4 Upgrade( ) Abandon( ) - 0 Complete System V Individual Components Location Owner's Name t:>A',1(ti iekka Nk� Map/Parcel# J`L� Address 165 W_0 E(,j)Up—t1q) TDP PA Lot# Telephone# Installer's Name CA CW MC— ��7�� � CLC Designer's Name N A Address 1 M A1;t4PEC_, Address Telephone# l 1 7— 8 g Telephone# Type of Building Pl^S Cb 7—IAL— Lot Size Dwelling - No. of Bedrooms Other - Type of Building No. of persons sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 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 ��5 �— EZ�J l D — �s The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees ton place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Ll —.8 -,P-z © E Inspections —IQ AS No. e,0H FEE �. C®MMONWEAI:T14 OF MASSACHUSETTS Board of Health,yagmnJ , MA CERTIFICATE OF COMPLIANCE Description of Work: Individual Component(s) ❑ Complete System µ t j e The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ai), pgraded ( )> Abandoned O p1t��j at l � CAM 17 3 t P -6Z-: 7— � yA W 0 0 has been installed in application No. Installer 0AIP& ,vith"tlfe p or1iisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated �— /" Approved Design Flow (gpd) Designer: NIA Inspector: 1!S Q -t Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. .t)�-.� �n�, ��,� �c?s t: -_r<.c �.^) ..�Z_L..� <?��C� L _ ��. t .C�'t Cr ^JC,; .. __ "'C.�" i __ _ in,�.. "�Cf UO L•nf n�>O �C�G J') 1, 0 C. 0 _^CwC;_C:1C FEE�J 00 COMMONWEALT14 Of MASSACHUSETTS Com- 3 N 91 � Board of Health, yf 1 1 , MA• DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(X) Upgrade( ) Abandon( ) an individual sewage disposal system at 1t a C AGK STQ&15-r-- as described in the application for Disposal System Construction Permit No. / /0 dated Provided: Construction shall be completed within thr f�thto of this p7mi . � l�lo�c/al conditions must be met. 65 Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date /� Board of Health