HomeMy WebLinkAboutApp-Permit-Compliancego*.pc-r6a0643 TR�) (�_ ISS �`�W-/ FEE $65100
COMMONWEALTH LTH Of M ASSAC14USET fS
Board o Health, Y4f -tOVT 1-� , MA.
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APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repai�Upgrade( ) Abandon( )-��mplete System ❑ Individual Components
Location 7
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Owner's Name T jk
jo S
Map/Parcel#
Address t`
Lot# -T
Telephone#
Installer's Name
Ke -1- Ze d �s7� /e�
Designer's Name
Address
^� G YWn
Address
,
Telephone#
�)� j
Telephone# e _
— xy
Type of Building Il t ?,04t,�i Lot Size ) SI (3 70 sq. ft.
Dwelling - No. of Bedrooms rhlee-- Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flowjjj
. equired) 350 gpd Calculated design flow S� Design flow providedT-36 gpd
Plan: Date G GIto 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 T,�S A,ea I soo ajlns Ee ht /G�1
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 place the system in operation until a Certificate of Co pl' nce has been issued by the Board of Health.
Signed � Date 0,511,0 &Q
Inspections
No. 60-nC4-106,q-3 FEE 5 0�
COMMONWEALT14 OF MASSACHUSETTS cA--* 33 r 2—
Board
Board of Health, Ypgm 0 V1 -1H , MA. 4
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 'Complete System
The under ed hereby certify th t the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade�andoned
sign ( )
by: <,c/' G l", ✓mac �,
at -/A al/i S� ti a %
has been installed in accordance with tine rovisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. G --/ Y , dated - /—%?. Approved Design Flow (gpd)
Installer Zj, /
Designer: , ice a•.SC_,— Inspector: i ^�n� Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. (60 WD C 6 0 Kl ie -vg-- l.."N7 641 STtZ FEE
/� - / -�-o COMMONWFALT14 Of MASSACHUSETTS 4
Board of Health, yA2.M0 UTA} , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair,' ) 'Upgrade( ) Abandon( ) an individual sewage disposal system
at �/ % C hi I .S 41,ts Gj y as described in the application for
Disposal System Construction Permit No. / 6:> , dated � -/1; .
Provided: Construction shall be completed within t e rhe date of this permit, All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date / �b Board Health