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HomeMy WebLinkAboutApp-Permit-ComplianceNo. B0ffDC—&-1 d7� FEE 7 7 f 6D COMMONWEALTH OF MASSACHUSETTS Board of Health, , MA. t .' z f G f7 � /.3� �, APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION P[RM Jw' ��application fir aermit to Construct( ) Repairx Upgrade( ) Abandon() ❑ Complete System dividual omponent pp���� 3 W U N Location $ Rt, Z$ - Fe� F0ce� Tacks Owner's Name EyAn L'1�(L Map/Parcel# 3Z/� Z /� Z Address S85 RT Z8 Lot# L a - G - 7- Telephone# Installer's Name�C)Ur C� Designer's NameC Gfou Address pp IS35 ddaACK BAOZrQ Address 3411,)4h T.v><; 02673 Telephone# 8_ _© FQ Q Telephone# Sm. �11 ` wapzz Type of Building Y�uX0.�Tf� / r Lot Size IO sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other -Type of Building ate✓ _ No. of persons a-�'$ Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) -7',C*X) gpd Calculated design flow 1C90L Design flow provided 16gpd Plan: Date _3- 1 D - 1 (P _ Number of sheets :9 Revision Date 3 - '30 - I to Title Desc Soil I DESCRIPTION OF REPAIRS OR ALTERATIONS . T_ of Evaluation � l •T 4 - /.c�rv,n,ry 4- u odd Ym, 4 IG -rr 0`09-4 �1 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provision o '.,L further agrees to not to place the system in op on until a Certificate of Compliance has been issued by the Board of Health. Signed U-9 • r3 • rytit-r� Date 5— ;LS — t i9 Inspectionse No. "''� FEE COMMONWIFALT14 OF Board of Health, �%. .M A i , MA . 7-/ CERTIFICATE Of COM PLIANC Description of Work: PIAalvidual Componeiit(s) ❑ Complete System it l io The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( ) by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and t/hje roved design plans/as-built plans relating to application No. % / J dated �`.�a� Approved Design Flow ;.a_(gpd) Installer , Designer: 6fnut? Inspector: YY 7 r r Date: The issuance'.of this permit shall not be construed as,a guarantee that the system will function as designed. No. J$aFEE1 C-tl- - L 11-753> COMMONWEALTH Of MASSACHUSETTS Board (f Health,' . t�'1 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) �aRepair ( } Upgrade (:� Abandon ( } an individual sewage disposal system at ri i �ri r" �.c2 f , l �i �i as described in the application for Disposal System Construction Permit No. != dated.- Provided: Construction shall be completed within_thx,�-s of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/9f6�A.M..'Sulkin Co. Chaadegoown,,MA -yC/ Date /5L—, N.-� ,/moo/' B6a"r/fd of'Heaalth APW A 1Li `2a`CJ .d l / '1iPc,� ..� 2 L�r_/