HomeMy WebLinkAboutApp-Permit-ComplianceNo. 650"c4o--81i0-7 � � FEE 00
COMMONWEALTH Of M[�4SSAC�USETTS (,0i° i
Board of Health, yaj?& 0 ()12J , MA. /
4� k- le'7'
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeXAbandon( 0 Complete System ,�dhddual Components
Location
1-01so
Owner's Name A o Qp l ',*/71-4/��
Map/Parcel#
Z % C41
AddressS l 5c)
Lot#
Telephone#
Installer's Name d2 l 11 �311� %� c7 o r j
Designer's Name P 14 �t✓ R®� �� e7// t
Address 3
IL011
Address '0 U qcd a
Telephone#
r
Telephone# f car '9, 3 7r'
Type of Building / . Lot Size 74;;100 sq. ft.
Dwelling - No. of Bedrooms Garbage grinderA4V
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3o gpd Calculated design flow 3-��• �` Design flow provided , S _ 7 °�gpd
Plan: Date a-i3i 1G Number of sheets _ 1 Revision Date 9 4a3%/d A
Title /f/e-f►/
Description ofSoil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation /`"
DESCRIPTION OF REPAIRS OR ALTERATIONS Re
The undersigned agree install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to L to a the to ' o til a Certificate of Compli ce has been d by the Board of Health.
Signed Date
Inspections
No. �� a. { Y!"�Ei d FEE . CPiJ
®MM®NLT`, Of MASSACHUSETTS c�(o¢0 i
Board of Health, 7� ,q7ZM d u374 , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 1� Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (Abandoned ( )
by: i= l ! a S 6,3 6_c i l',a CS C o ,";I
�.,
at �7 lr��F Z f�/!t@. ✓- .. cl,;,r-,r�cs�^rSl � I`�"i rl
has been installed in • ccorda ce with the provisions of 310 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application No. dated " /6i . Approved Design Flow ': f.K�. Ei (gpd)
Installer I.�_ I r i
Designer: /) GT Inspector: e�C P Date:
The issuance of this permit shall not be construed as a guar' tee that the system will function as designed.
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FEE 00
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COMMONWFALT14®L' MASSACHUSETTS
Board of Health, ,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgraded Abandon( ) an individual sewage disposal system
at n% as described in the application for
Disposal System Construction Permit No. �t'n ,dated
6=?111,'L-/t--C'6D7
Provided: Construction shall be completed within of the date of this permit. All local conditions must be met.
S //j�
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chatlegnn, MA Date / Board of HC
Health