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HomeMy WebLinkAboutApp-Permit-ComplianceNo. �7 "c-��O -td %'l p o� - -, -�l�Cr �� �' " FEE �✓ S 16--110 C®MMONW LTH Of MASSAC14USETTS 3S2(a Board of Health, Y ?t,nA , MA. APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(o Upgrade( ) Abandon( ) - ❑ Complete System JI (Individual Components Location t t `--J- Owner's Name kP-i!5-reN HavuAtct> Map/Parcel# Address C CJ d G m Lot# Telephone# Installer's Name ( tj� Designer's Name N Address 63 0-164A NA<,k1 Peg Address Telephone# 5,p? -t f -Z 1 -7 Telephone# Type of Building �--E Dwelling - No. of Bedrooms Other - Type of Building _ Y No. of persons Lot Size sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures �I-� Design Flow (min. required) V gpd Calculated design flow � Design flow provided -104647,-X?��-�X? gpd Plan: Date Number of sheets Revision Date Title Description of Soils) - Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree to�no cethe system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ( Date 15 d;t o -,;Xc) l (O No. 6014 DC 46-10-7 8� /�Sr i'f G ///FEE COMMONWEALT14 OF MASSAC14U Tel F: Board of Health,I� i�� (� , MA. CERTIFICATE Of C®MPLIANC� Description of Work: Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.,.-; pgraded ( ), Abandoned ( ) by: , U.11 : C --);i - - fP st`S I LL <— has been installed in accordance with the provisions of 3;0 CMR 15.00 (Title 5) and the ap ved design plans/as-built plans relating to application No. i dated Approved Design Flow r =�Pd) Installer )7ne Ps Ki -SK t•LX-' r Designer: ►.1 -A Inspector: The issuance of this permit shall not be construed as a guara the system will function as designed. No. FEE — CAP � t�� COMMONWEALTH OF MASSACHUSETTS :3524, C) Board of Health, VVfLli1©(37�- MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(() Upgrade ( ) Abandon ( ) an individual sewage disposal system at i P �✓i`I l ��! ('$. � js J lac J 'i�gm ( -� as described in the application for Disposal System Construction Permit No. dated. "//� , dated . Provided: Construction shall be completed within three years of the date of this perrwtIM- local conditions must be t,1. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date -4 _4oard of Health tjai :Zk i