HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6041)c—
C®M�1[®N �.T ® ASS CHUSETTS
Board of Health, I AMO O ( T1 9 , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct pair( ) Upgrade( ) Abandon( ) - .ld"t:omplete System ❑ Individual Components
Location
6 5t L_& p/1H
Owner's Name I'(Ai( 1,10 —
Map/Parcel#
(j 5 2 ?
Address ss 0,0r 1w)
Lot#
Telephone#
Installer's Name
S�C,4 {<'/`L,4/✓�lJ p�Ji LCC
Designer's Namec5rL k SCINS INC
Address S
rC—A K -,,)A&1 Nlv&/ )ICM
Address ( Cl 1'9) - C— 54,A/,01J(C1 1
Telephone#
09 4S,?— 53-65'
Telephone# SO 77 6 66277
Type of Building Lot Size 16 t 00Z sq. ft.
Dwelling - No. of Bedrooms 2 Garbage grinder ( )
Other - Type of Building No. of persons Showers( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 22 Q gpd Calculated design flow Design flow provided 342. 3 gpd
Plan: Date 1111115 Number of sheets 3 Revision Date t I 1 LSP i I S.
Title (, I ?E /li✓r� i f� [ t IGEN
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator "W,- AC 10-9 Date of Evaluation Aj 1511
DESCRIPTION OF REPAIRS OR ALTERATIONS 5GO-f I C _ -0 I d)- O oyc T 4s ,
The undersigned ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signe Dateo_,S _A�,
Inspections
COMMONWEALT14 OF
Board of Health, y,amnu-) , MA•
n
CERTIFICATE Of COMPLIANCE d 1 r 0 1 _ t -3 - `6 -
Description of Work: l7 Individual Component(s) �mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (K), Repaired { ), Upgraded ( ), Abandoned ( )
at
has been installe/n a
application No.
Installer 5,
rO(4TTI 70
o_
mewh the
itlov cions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated Approved Design Flow 1, (gpd))
Designer: ,V C' -f Ole 1 '-/C • Inspector: V�?pate:
The issuance of this permit shall not be construed as a guarantee drat the system will functionas dsrgned.
No. ,�p �o —� 1c"� 8�C 1''� . FEE
�-
COMMONWEALTH Off' MASSAC, HUSETTS � 10 (003
Board of Health, � Prli V10 uT14 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( >}' Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at !.� ?`� S h,�1 �`� as described in the application for
Disposal System Construction Permit No..1r, , dated 3--1
Provided: Construction shall be completed withins of e date of this permit. l local conditions must be met.
i1Tr�^�e-ye� thS f
Form1255 Rev... 5/96 A.M. Sulkin Co. Chadestown, MA Date' ` T% B(oakIdWof Health V