HomeMy WebLinkAboutApp-Permit-ComplianceNo. �/OQQ Gr � FEE L00
COMMONWEALTH Of MASSACH �ETTS �3�9
Board of Health, ) $39M 0 tMj , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade AbandonO - ❑ Complete System -C Individual Components
Location ((510C,44"
J
Owner's Name OC'" 1/0 �Z%Zm�AA
Map/Parcel#
13 toF-
Address eft s L -,4 / 4ctp,4-9314
Lot#
Telephone# S cy $-
Installer's Name
`d l� ar Ca�1,I `
Designer's Name ballk,i'
Address O^t,3
J;3,0,wr �{/r
Address 13 5 s' - &Qc�/o-
Telephone#
c.�
Telephone# G L4S,44'
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building
No. of persons
Lot Size f sq. ft.
Garbage grinder
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) a gpd Calculated design flow 3Y Design flow provided --t— gpd
Plan: Date Number of sheets Z Revision Date _
Title /f%d/t� C: l'! /t/0! L7'�� �ld� --sZ �y�'+7✓�'`�
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator -�Ce12.4,Z4 h9 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS &PmAe-17
�
The undersigned agre to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to pla the s to . tib' until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
e
Inspections
COMMONWEALTH OF MASSAl.itltil SETTS
Board of Ha'ealth 7► MA
FEE 0�
CERTIFICATE Of COMPLIANCE
l�
Description of Work: .Qlndividual Component(s) ❑ Complete System
The iYndersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,j,,}-Abandoned ( )
by: - HIS S C J-)4 "s
has been installed in accordance with the rovi§ions o 10 CMR 15.00 (TitKe 5) and thea proved design plans/as-built plans relating to
application No.&7-��, dated pr _ / Approved Design Flow (gpd)
Installer .i'c� i�,�•�..? ..s� r • ' ' l .fit' t'}^ 1%✓" -i
Designer: au'i-+ fi-%f 12-fA.psspector: ,�' Date:
Td -
The issuance of this permit shall not be construed as a guarant that the system will function as designed.
No. i r°lC FEE 00
COMMONWEALTH OF MASSACHUSETTS,
r` Board (f Health, _ , MA.
DISP®SAS. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No44
as described in the application for
Provided: Construction shall be completed within *ham? sof thedate of this permit. l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ��lo BoarCl Of tlCalth� '
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