HomeMy WebLinkAboutApp-Permit-ComplianceNo. 4PC- 1x/-0327 /oe,) G' u�(�� ry /�iy` EE ��00
%- // COMMONWEALTH Off' MASSAC USETTS "?o6a
Board of Health, Y&I►U VIV MA.-
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to
nstr c )Repair ) p radeO andon ❑ CompletgSystem C�Individual Com nents
Location
Owner's Name $,.
Map/Parcel#
JL,�V
Address Io
Lot#
Telephone# 17u - LjS'1 - y 7 q
Installer's Name�3
,j�j,
Designer's Name je„5-c-
Address .2 -3e,
� �%, a
Address 3 4 I W AI N S.t
Telephone#
j-
3 & 7,
Telephone# 5'27 0 -`7'7e - V 147
Type of Building IP -4,7` ?�? AAl + ' Lot Size 3zl 792 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder (tiff
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
l
Design Flow (min. required) 71g-
gpd Calculated design flow
Plan: Date �6-- �� Number of sheets
Title-� L=' R ��
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Design flow provided gpd
Revision Date if
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS QrA00 - G ?�;
The undersigned agrees to_.)nstall the above describ d In4jvidual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to notac'th yste in o io ertificate of Compliance has been issued by the Board of Health.
Signed Date 3 V f
Inspections
11.0
COMMONWEA1LT14 OF MASSAC14US ETTS
Board of Health, A Ca.�l� Cl L]`� "4 l ; MA.
CERTIFICATE Of COMPLIANCE
W
FEE 00
(o0
Description of Work: eel dual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade aandoned ( )
by: z. - v j /-
at ,r+,di . -_ _i_ y
has been installed i accord nce with the ovi iorns of CMR 15.00 (Title 5) and e roved design plans/as-built plans relating to
application No. j / dated ry�! /19 Approved Design Flow (gpd)
Installer
Designer: f- " Inspector: Date: 4/0
The issuance of this permit shall not be construed as a gu antee that the system will function as designed.
FEE '55 0
COMMONWEALTH OF MASSAC USETTS
Board of Health, yO� n[)*=_, MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( j" Abandon( ) an individual sewage disposal system
, 1
at S i� S-7 y/ as described in the application for
G11Disposal System Construction Permit No. (, dated
Provided: Construction shall be completed within three years of the date of this permit. l local conditions must be met.
p _ � P� -�
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date , Board of Health r