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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ba -De- 1 � -13 1(O /`' r` / 7 " !, / J-5 FEE j S67, MONWEALTH OF MASSACHUSETTS G &q3 (o Board of Health, _ 04 MA. APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT a �" A" li atron fora emit to Construct ) Repair( Upgrade( ) Abandon ) - Com Tete System ❑ Individual Components PP � ( P ) Pg ( ( P y P Locationd� Owner's Name r- ,t,( A Map/Parcel# Address Lot# , is Telephone# Installer's Name ��� © Designer's Name w Address f S' �e J Address br Telephone# -4 Mo vL� Telephone# S" t)0 Type of Building Lot Size sq. ft. Dwelling - No, of Bedrooms Garbage grinder( ) Other- Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min, re uired) v, gpd Calculated design flow Design flow provided gpd Plan; Date 49-1 � � � Number of sheets r Revision Date Title Description of Soil (s) j /17,4 Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF PPAIRS OR ALTERATIONS / !.tf,�/ Date of Evaluation I2— 7 , �6 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees too no�to lace thet m peration until a Certificate of Compliance has been issued by the Board of Health. Signed / _ i Date % d -- Z' S Inspections //6 //o SO% t or 'U'V kio/ 040 T No. 1,xn C 40-13 i (,o f FEES COMMONWEALTH OF MASSAC14USET Board of Health, MA. oo�4^„ CERTIFICATE OF COMPLIANCE NCS Description of Work: ❑ Individual Component(s) Qkomplete System 'd j 17 The undersigned /heere�by,cce+r - that the Sewage Disposal Sys em; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by. /.7 at has been installed in accord_a_ncy with the provisions of 31D CMR 15.00 (Title 5) and the a rovedsign plans/as-built plans relating to application No. J dated"':,, Approved Design Flow Installer Designer:�� ,r�� — ' Inspector: %`C t-��'8Date: The issuance of this permit shall not be construed as a guarant a that the system will function as designed. No.F- x)"1 10 FEECOMMONWEALTH Of MASSACHUSETTS q 3 (C7 0 Board of Health, -�--, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(�Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system /i" at 'Fo /;,.-r e�/V , � , as described in the application for Disposal System Construction Permit No. , dated /0 . a Provided: Construction shall be completed within tbrre ea4o�date of this perms l local coiiditLQns must be met. ff Form 1255 Rev, 5//96 A.M. Sulkin Co. Chadestown, MA ♦ Dated` �•� �t'� �$ord of Health 70 l Cr J v;'3lsj �1�� /7'�LAi!J _ /r .r • i.—,/G �Aw14