HomeMy WebLinkAboutApp-Permit-ComplianceNo. �"µ� `� 16" 14f f' LP 7- 60
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FEE
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Board of Health, ��/A-iLMnk� , MA.
APPLICATION FOR. DISPOSAL S TEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) Complete System ❑ Individual Components
Location
LA10
Owner's Name C'k
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
P4W CO -k
Designer's Name u yl 1C (,` d rr\ S e r V I`G
Address voN+
anai
Address G (,;
Telephone#
Ot "a (D:)'
Telephone# S'p
Type of Building DL J.0 Z/-,�Lot Size � sq. ft.
Dwelling -No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided d
Plan: Date 1 i�,1rF Number of sheets Revision Date
Title i✓e-46%1 Arra e � A-0',0on/GA✓Ta � 6� e s .>, JP- d 4 eLo V
Description of Soil(s);� So,� �,GZ
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 5-e P S egi C, S i - p rn
The undersigned ag4tQ, ll theebov es ed dividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees toet until a Certificate of Compliance has been issued by the Board of Health.
Signed (� Date
Inspections
o C®1°Al°ll'lYl� �'V' jC,fltLT14 OF MASSACHUSETTS
FEE �l��Ol�
Board of Health, M+ , MA.
CERTIFIC fi Of COMPLIANCE
Description of Work: ❑ Individual Component(s) System `
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (mdoned ( )
by: i ,1 1 . �. ;)
at � -E 6') �i
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) an the a proved design plans/as-built plans relating to
application No. dated %/^` Z '�6 Approved Design Flow (gpd)
Installer I,
Designer: : V , (rf�ljector: AAAAK Date:
The issuance of this permit shall not be construed as a guar " tee that the system will function as designed.
No. Pb T) C 6 " 1 G fit FEE
-�1/XS COMMONWEALTH 7C.ALTH O MASSACHUSETTS
° Board of Health, ywr}± 'MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted "to; Construct( ) Repair( ) Upgrad,. -<Abandon ( ) an individual sewage disposal system
at 9G q iN VVV (; i ce, i }ti> t f ` �� 1 as described in the application for
Disposal System Construction Permit No. 1 4p, dated
Provided: Construction shall be completed within tie-yeVs"of the date of this,, e t. All local cond'uons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Dat
e% —/ Boar ` o4ealtli Cr`iG ,