HomeMy WebLinkAboutApp-Permit-ComplianceNo. -0 23ro S` D ! n' l -7 ""' 0 Q 1 1 10 FEE
G - z21 L/ COMMONWEALTH Of MASSACHUSETTS /4� �e ( �
Board of Health, g&oy-n+ MA.
yLAPPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete Systems4::6ndividual Components
Location R6
Owner's Name%-.Tr;h 6CU a t
Map/Parcel# `j
Address 1 irt, 6rm. YArmvrN�
Lot#
Telephone# 52$
Installer's Name C
Designer's Name
Address �'-1 S + � p C,
Address 12+ GO �(7%
Telephone# _-,5b2)Telephone#
Type of Building 7 n� 1 C.�� Lot Size 1519'`'1 c) sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers( )—Cafetia ( )
Other Fixtures
Design Flow (mina required) gpd Calculated design flow JV(RC Design flow provided r gpd
Plan Date �1 it, t I to Number of sheets i Revision Date bed ru__
nI c' , nl
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluatore5C G ��TIJ1� Date of Evaluation Z11-1111,
re, o6cciy)n I�ca�1 QJ (A C_rP�
The undersigned grees to ' ove s ' ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree tem operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Z131llto—
Inspections
No. 1 CC - (n --0 Z
� - -21
Board of Health,YYn4 MA.
CERTIFICATEOF COMPLIANCE J4,
Description of Work: �Wrfndividual Component(s) ' ❑ Complete System�bgl�?,�16
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (..�-�Pibandorled ( )
by: a C C d n..1 4�-VLU c•Z1 6,\, i % N C
at ! f 6-a O ye- t� D
has been installed in accorda cee�� tl revisio►o of 310 CMR 15.00 (Title 5) and the roved design pians/as-built plans relating to
application No. ate O4 f4 Approved Design Flow _J3�(gpd)
COMMONWEALTH OF MASSACHUSETTS
FEE
Installer
Designer: 'E;r, C" ( 1z)o Inspector: �f'"�L.�"�L ' Date: >
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 0 C-4 l (�/ 0 r' FEE ! 9Q22
65o 'D C - (16-6-Z3J�3 COMMONWEALTH OF MASSACHUSETTS
Board of Health, ',tAJiXt•�lj— MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (�bandon ( ) an individual sewage disposal system
at
as described in the application for
. rr
Disposal System Construction Permit No. s'- %, dated
Provided: Construction shall be completed within tLxeea,&wr.,rof t4c, date of this permit. All local condi ' ns must be met.
Form 1255Rev. 5/96 A.M. Sulkin Co. ChadeIrl-,
•tmvn,� Date " 'l Board of Health
�.,.� // -A, /l stir ` l .n s <, . A!�_