HomeMy WebLinkAboutApp-Permit-ComplianceNo.
604DC-1 P40c1(a 3Lm-if- Dow, 09
/4 -j,)- � COMMONWEALT14 OF MASSAC14USETTS
FOR
of Health, )49M o dT t4 , MA. )S „�
APPLICATION ±COR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(j(Upgrade( ) Abandon( ❑ Complete System ❑ Individual Components
Location
Type
Owner's Name
j
Map/Parcel# 9g
Address _'s. CkfY`(10
Lot#
_4C2�Ccy
Telephone#
Installer's Name prem 00 Ca �.s :r) (Z'
Designer's Name BSL Gnmo
Address31 Ro , _ �'
Address q k+
Telephone# --s-
Telephone# -15'09-77.3- ISV9
15'09-77 3 -
,a_, _ R"
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Other Fixtures `-
Design Flow (min. req 'red) T 0 gpd Calculated design flow Design flow provided gpd
Plan: Date �% A 1 1p Number of sheets Revision Date
Title M D / .5 11 X9 C•J/—
Description ofSoil (s) Q.AC
Soil Evaluator Form No. Name of Soil Evaluator Klif.12A OAdu Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 pla system in o ation until a Certificate /of qom Iijli c been issued by the Board of Health.
Signed x• Date (� L
i
Inspections
Ae
No. bCA6-j09 10
0 F 5Y 00
COMMONWEALTH OF MASSACHUSEI
Board of Health, V!� (�PVI01Z71± MA. Y� ,
CrIDTIFICATU f CAM I1ANCIE
Description of Work:
The undersi ned hei
by:
at 1'i
❑ Individual Component(s) ❑ Complete System"�
�y certify that the Sewage Disposal System; Constructed ( ), Repaired IO, Upgraded( ), Abandoned ( )
!\
has been installed inacco:
application No. 6
Installer M), M 0" r
!2�_ A 6K4 44 _ :��'r ri X • f 44 ifs i ire_
with the prvisio s ofd 0 CMR 15.00 (Title 5) and th approved design plans/as-built plans relating to
dated` / Approved Design Flow (gpd)
Designer: & _S1 Inspector: /"r Date:.
The issuance of this permit shallnot be construed as a guarantee that the system will function as designed.
No. 6- 6"DC --K—) � 1 C0 h T-,tA cTb(L5 FEE
le, COMMONWEALTH OF MASSACHUSETTS
Board (f Health, )(A74,.yvl n l Jr r+ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissiop is herebygranted to; Construct( ) Repair ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 4Q as described in the application for
Disposal System Construction Permit NotC'7 - - , dated io
Provided: Construction shall be completed within of thedateof this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date r� Board of Health