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HomeMy WebLinkAboutApp-Permit-Compliancey 47 1 bee FfE l6 ``f COMMONWEALTH OF MASSAC14USETTS a��7 Board of Health, Y09i°V1O(14 , MA. APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location 4 L yT t c,+C.r �vg Owner's Name le�Rl -ra,f D w Map/Parcel# _77161 Address -:�p (!,jai AA/l)©v-PZ MA Lot# Telephone# Installer's Name (!APV,.j Designer's Name Address �J C-� Address Telephone# So 7 ., i Telephone# Type of Building R ES i pt5�?l t! i 4-c, Lot Size 140, 2 9 6t sq. ft. Dwelling - No. of Bedrooms 4f Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided 49]�, " /4 gpd Plan: Date Number of sheets Revision Date Title Description of Soil (s) Soil Evaluator Form No. 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 agrees to not to place the system in operation until a Certificate /of Compliance has been issued by the Board of Health. Signed r i c C:" a/ Date (fd -b `/It' -1;014 a No.bc-%C�/�,� CSSl� E COMMONWEALTH O FSSACH J STT Oa4 b Board of Health, A -f M D t ?TJ , MA. CERTIFICATE OF C®MPLIANCE Description of Work; ❑ Individual Component(s) ❑ Complete System ( �,,,%�� The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (X), U graded ( ), Abandoned by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-4 application No /`4 dated--.. //�� G. Approved Design Flow�(gpd) Installer Designer: Inspector^ Date: The issuance of this permit shall not be construed as a guarante-I that the system willfunction as designed. COMMONWEALTH OF MASSACHUSETTS Board of Health, _ Aaama IIT vm DISPOSAL SYSTEM CONSTRUCTION PERMIT plans relating to FEE_',` hl Permission isrhereby granted to; Construct( ) Repair OO Upgrade( ) Abandon( ) an individual sewage disposal system at 15 ( l / 041- Z- — as described in the application for Disposal System Construction Permit No. "A4 � , dated A Provided: Construction shall be completed within three years of the date of this pea -Mit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesi m, MA DatBoard of Health �d