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HomeMy WebLinkAboutApp-Permit-ComplianceNo. bWDCA V7g7 FEE C 6��16"101K F4AVAC BUS E T TS Board of Health, iCArM ®M APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( - ❑ Complete System KIndividual Components Location Pt (� An iwov_ I-Aas Owner's Name b 1'--- At4 134 -Tc— s Map/Parcel# geo Address -k,( CARZIOAL, LA06 `/J VAP, Lot# Telephone# Installer's Name �� 1 ���� LLC_ Designer's Name l v Address C� t A�L S -u- ajQe5, Address Telephone# 6o,2 _ 471 .. g Z •7 Telephone# Type of Building PE.SlD&--A)T/ A -L_ 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) f gpd Calculated design flow Design flow provided te: 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' z� 6A1'WtxCL-Y TFC du i- ov-Tq - /s /� G/ ate." 4 r ,.L. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to n place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date AD — (0�-i� Y r Inspections .> �� I Ca w e7CJ �''E' 1 ✓� �c.E CC") S 1) �,_; No. 4 00 COMMONWEALTHOF lMASSACHUSFTwi—,E FEE Burd of Health, YF� t2�1�101. , MA. / CERTIFICATE Of COMPLIANCE ��� �.%� ,��' Description of Work: X Individual Component(s) El Complete System The undersigned hereby ce?�"Tap,?AL-�M ht the Sewage Disposal System; Constructed ( ), Repaired x, Upgraded ( �'Ab ndoned ( r by: C A_ at A(C:r4RhlNd�c.. 4-ii�[U6 WAST 1%r41©u'1 has been installed inaccor/d ce with the provisions of 3 0 CMR 15.00 (Title 5) and pproved desin lans/ s -built plans relating to application No. " f/ dated Approved Design Flow (gpd) wry/ V U Installer CAP (RoO[ D46 Designer: N LA Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. &QUIX--1ta^-1UN-7C gyp( LJ+ (�� FEE 05>-00 COMMONWEALTH Of MASSACHUSETTS Board of Health, Y49 -M 0 tYM , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair`Upgrade ( ) Abandon ( ) an individual sewage disposal system at oll (2ARl� 1 AJA-i . &A�W 6 C -ST 7 A OUT4 as described in the application for Disposal System Construction Permit No.,1,--/// , dated -(- / Provided: Construction shall be completed within th,lge,y&.ar&ofth/�e,,date(of this permit. 1 local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestm, MA Date ^� oard �c�alth, c /w/