HomeMy WebLinkAboutApp-Permit-ComplianceNo. 4E4 q C—IL-14 `�7 � L l �., / ,/— Fi o� O�3/
COMMONWEALTH OF MASSACHUSETTS
Board of Health, T��W Kl , MA.
FEE 4515_'00
ck* 35
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(. Abandon( ) - -a Complete System 0 Individual Components
Location f L<ls
Owner's Name
Map/Parcel# JC-
Address CZe P, fit% /�j liv ct ? /.c vr-st 'S
Lot#
Telephone#
Installer's Name D i'J m o o D4,1`011_
Designer's Name H H e V,/W O/K S h G
AddressJ o n e, p�
Address Z �/� C"',& 6s1 'ell /2 FG
Telephone# S`o q -3G g . g 5�'7
Telephone# Z 6 O,j
Type of Building Lot Size /h. (/w sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder( )
Other -Type of Building s�c�Efla� No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 �� gpd Calculated design flow 3 3 a Design flow provided 35 gpd
Plait: Date Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OFREPAIRS ORALTERATIONS /y�� _��Gl�oo�* � CTS/eP¢�G s%j�Le�t
Z ,Q Q 64,11-1- S TIC /
{�.,aC )rS, ; Gdd 1,1iH 64 ar✓h F�-�!� I S �rt -2
The undersigned agrees to instal a ° i ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees tone1ystem inAwwdrn until a Certificate of Compliance has been issued by the Board of Health.
Signed Y i Date
COMMONWEALTH OF MASSAC14USETTS
Board of Health, )6 r-yi'i , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) 31C, omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (-f Repaired ( ), Upgraded Abandoned ( )
by: l�i ;1-71A, 0 0 u 0, 7 d tDAr, r, `r+
at 1-7 A 1,4 rt
has been installed in accordance with the provisions o 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. % G._ dated Approved Design Flow (gpd)
Installer _Se__ - P1 A,4,01
4,01
Designer: -_ANG 1 N "� i NG-WQ _ Inspector: Date: 144 7
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
()N"D(J"b—tC11 _7 u 130N4 SEDJ0Z--h_�)QAI+v FEE
COMMONWEALTH OF MASSACHUSETTS
Board (f Health, mO- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(bandon( ) an individual sewage disposal system
at J"7 as described in the application for
Disposal System Construction Permit No. — dated
Provided: Construction shall be completed within three years of the date of this p it,.�^A%llll local co "tions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Chadeslown, MA Date Board of Health
WA