HomeMy WebLinkAboutApp-Permit-ComplianceNo. i(J� YC'�b��I FEE S-5.00
0-7 1
7 COMMONWEALTROFMASSACHUSETTS b L1DT 1, - r 7 - coo zq
Board of Health, AgMYDpi , MA. �/ 1 �j I 1/ l.�"'' "
p"'41,;&PLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ) - ❑ Complete System dual Components
Location 2Z =Ro Q L) oms JGLVj)Owner's
Name 3p►1f-, 1-0.
Map/Parcel# SZ ig&
Address ZZ. _ L
Lot#
Telephone#
Installer's Name ,
Designer's Name p a F— J 2.
Address 1 c.rr N �Oi'C L
Address YarMdt-H\�,
Telephone# 0 Jr
Telephone# L _ LIS
Type of Building Lot Size ) 3 S 4 O sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow Design flow provided —09 gpd
Plan: Date Number of sheets ! Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS H 1 O -D PDX - IL d 2 o 141c 2i1 -'r ) 4 r ,:x-) O(' S
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 !l)OV ?1- 1 �,
FEE
C14
COM[M ON LT14 Of MASSA CIIUSETTS c c 0-7 i
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE �
Description of Work: 96ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired (�UPgraded Abandoned O
by: OA)
at 2Mf,20000113 1121LU O
has been installed in accordance with tlt�e\\provisions of 310 CMR 15.00 (Title 5) and the pproved design plans/as-built plans relating to
application No. .3/t 7 , date 1 / fl Approved Design Flow •°f (gpd) .
Installer F�r
Designer: -�OWtJ CAPC- Ck6 1 ( 4-Q-(!J(SInspector: Date:
The issuance of this permit shall not be construed as a guarana that the system will function as designed. y:.
_600u. c_�c000 n.-,oan,i.a>ocionac oc,..cu._o�vur, 'c nu., ci .,n iota-ao_ ok.no au+ _, c, ..ate ok:4-._o-t>o+i<3c, coc.rt�.la.�,:u-cil.F-�c.u..i at; nor. ric._. .»c,.:c
No. 6 C.iE C Pi FEE 4550 00
COM[NMONWEALT14 OF M ASSACIIUSETTS
Board of Health,, � 1L10 ( 774- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (X Upgrade( ) Abandon( ) an individual sewage disposal system
at Cg Q-7- R 0 o a p 1 5 as described in the application for
Disposal System Construction Permit Noz :tel , dated /1.
Provided: Construction shall be completed withinars of t11e date of this perm All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date t) -(-,-6/Board of Health t % /j L/