HomeMy WebLinkAboutApp-Permit-Compliancet
to
Z
Z
P)O{JU� 'I W� ! n,51'Jo4 / FEE 55� �'
No.
06(,p a -7 6 � Ne-
/� COMM® L.TH Of MASSAC14USETTS
Board of Health,11IA•
APPLICATION FOR DISP®5STENT CONSTRUCTION PERMIT
plication for a Permit to Construct Repair( ) Upgrade Abandon() - )(Complete System ❑ Individual Components
Type of Building �-� f.�E►�t"���. Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder, o
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow 330_ Design flow provided �t/- (2 gpd
Plan: Datey���/� ;2.2 Number of sheets I Revision Date
Title `j i �f'6'� '� . SJ�JY/ i � .5�� ✓ w A4 op6e p,' ►+
Description of Soil(s)
Soil Evaluator Form No. �� Name of Soil Evaluator P� V, Aloweartfi Date of Evaluation'-,-b/NJ9' `2,� 24166
DESCRIPTION OF REPAIRS OR ALTERATIONS
I�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre to qot to. lace the em ' peration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �'� 12 `4'
s
Inspections
s f
No.)ar nr(p "J11 COMMONWEALTH Of l�llSSi�1�JS Ae
4_
�FE� `�(j� f
49
Board of Health, --- I f-�tj l , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 1 Complete System
The undersigned hereb certify that the Sewage Disposal System; Constructed, Repaired ( ), Upgraded , Abandoned ( )
by: 1 l,4A-j � �/.�'.�A-wog' Lojc47" 54,RA ours -4 Ali- -Oa6 �',S
at
has been/Iinstalled in accordance with the provi ons1of 3L0 CMR 15.00 (Title 5) a d the ap roved design plans/as-built plans relating to
application No. f J" dated 0 - "�6.' /'IlApproved Design Flow; -bpd)
Installer �4 J:�d-•/J' a
Designer: v W. l kAjar✓t C% Inspector: % Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No. FEE —55'
COMMONWEALTH OF MASSACHUSETTS �`3�1
Board of Health, Yolemb bt 4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct() Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at .5-7 A413j W0AJ C>R1VR' UAW -4-7- }`29R.Al lf1-PA4 / as described in the application for
Disposal System Construction Permit No../--, `, dated _6 -- �&�r10
Provided: Construction shall be completed within thr.00-ye-axs• of the date of this permit. AR40 conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, M Date ��1�� oard ofHealth
Owner's Name.9)t60L•LA 11j AAJS'13R 614
ocation L>AlV-"=-
Map/Parcel# 8
Address 57 /ABYt'11 �9�t1 OeZ���'
Lot# 14-
Telephone#
Designer's Name Donald W. Moneevicz, P.E.
Civil Engineer
Address 40 Pond Street
Telephone# West Dennis, MA 02670
Installer's Name �3A1AAJ G. Jrs�`-'J�G
Address �7 ��w� �✓� �' /'`o�D
Tel ephone#C FS
Type of Building �-� f.�E►�t"���. Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder, o
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow 330_ Design flow provided �t/- (2 gpd
Plan: Datey���/� ;2.2 Number of sheets I Revision Date
Title `j i �f'6'� '� . SJ�JY/ i � .5�� ✓ w A4 op6e p,' ►+
Description of Soil(s)
Soil Evaluator Form No. �� Name of Soil Evaluator P� V, Aloweartfi Date of Evaluation'-,-b/NJ9' `2,� 24166
DESCRIPTION OF REPAIRS OR ALTERATIONS
I�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre to qot to. lace the em ' peration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �'� 12 `4'
s
Inspections
s f
No.)ar nr(p "J11 COMMONWEALTH Of l�llSSi�1�JS Ae
4_
�FE� `�(j� f
49
Board of Health, --- I f-�tj l , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 1 Complete System
The undersigned hereb certify that the Sewage Disposal System; Constructed, Repaired ( ), Upgraded , Abandoned ( )
by: 1 l,4A-j � �/.�'.�A-wog' Lojc47" 54,RA ours -4 Ali- -Oa6 �',S
at
has been/Iinstalled in accordance with the provi ons1of 3L0 CMR 15.00 (Title 5) a d the ap roved design plans/as-built plans relating to
application No. f J" dated 0 - "�6.' /'IlApproved Design Flow; -bpd)
Installer �4 J:�d-•/J' a
Designer: v W. l kAjar✓t C% Inspector: % Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No. FEE —55'
COMMONWEALTH OF MASSACHUSETTS �`3�1
Board of Health, Yolemb bt 4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct() Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at .5-7 A413j W0AJ C>R1VR' UAW -4-7- }`29R.Al lf1-PA4 / as described in the application for
Disposal System Construction Permit No../--, `, dated _6 -- �&�r10
Provided: Construction shall be completed within thr.00-ye-axs• of the date of this permit. AR40 conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, M Date ��1�� oard ofHealth