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Home My WebLink AboutApp-Permit-ComplianceNo, _ 3q V L.w'�� FEE 466-,00 p S CON1 MONWEALTH OF MASSACHUSETTS if Board of Health, /� , MA. ,q,C letz APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT I Application fora Permit to Construct() IjFpai() rUjgra�le AbandonO - EJ Complete System I�Individual Components ��4� s� / Location C►'�l r) 1^ U AC (O"RA Owner's Name j Cle 1 S .S Map/Parcel# -30 Address /Q 22 taLfC VKw ®r (•eda, 6-mv e k< - Lot# Ls .Z �4T,,t &ft 7Z 49, i9 Telephone# 277-31 Installer's Name �� i�r fz1�1.i f & C it n CJI�c*yfa I k C Designer's Name ` .,,A ee Address 1? 0, /�✓craC f t %Ake-Y:lle M."Z6 3 Z Address l ZZ kU, C,_Vjr-A,eId 4W jz©Y.L�ci,UP Afi Telephone#' Q- -CIQd Z/ Telephone# g- %7-5-3f on y Type of Building I2 5zCkte1d__fa, f Dwelling - No. of Bedrooms Z `t i,,t Qct, ( J -'^_5 Other Type of Building 2 13 Id c+ --OL >e Sy S fiP"4 S No. of persons Other Fixtures Design Flow (min. required) C__ Plan: Date 9 Title s� 4-& Description of Soil (s) Q '4 A Soil Evaluator Form No. Lot Size 17, 6 c i sq. ft. Garbage grinder ( } Showers ( ), Cafeteria ( ) gpd Calculated design flow l n Design flow provided Z % 3 gpd Numbir of sheets � `�� (� /�� , �, ®Revision�Daate Al i- k- . �-0 � pta, Zap 6wn'b t rry x 4 ';B �.�'1l !'� �' ' ' " •'" Lg l2 i �S� Name of Soil Evaluator '12e vY Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 1 "S4_1CH e/%Z .Sae c cf i f e. c Leat" I. -e— co/ 4' Sftky g Ridgy The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date A F Inspections No. 1304 ��--il =� .FEE�� Board ofHealth, Yq� CERTIFICATE O � _ ,>IP IANCE . Description. of Work: N1'Tndividuat Component(s) Ll Complete System W�y< 11a'a The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: 1 L , has been installed in accoydapce with the provisions.of 10 CMR 15.00 (Title 5) and th a proved design plans/as-built plans relating to application No. I dated l li 7 . Approved Design Flow (gpd) Installer T,oriO4- k r1 oiAliy...1 Designer: L" I bji:(- i WG i)r) spector: The issuance of this permit shall not be construed as a guarantee that the T No. - will function as designed. COMMONWEALTH OF MASSACHUSETTS Board of Health, 4��t ✓'r"� tM i- , MA. DISPOSAL. SYSTEM CONSTRUCTION PERMIT FEE - Cf Permission is hereby granted to; Construct( .) Repair( ) Upgrade 0<) Abandon( ) an individual sewage disposal system at 6✓a.t 4jen , bi t°r a'e� c� !F? A as described in the application for Disposal System Construction Permit No. , dated Q `" q:141 Provided: Construction shall be completed within, o e dAte of this permit. All local conditions must be meta Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Dat °" Vi' y°r Board of Health '!