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HomeMy WebLinkAboutApp-Permit-ComplianceNo. V o D Col 7—Z-91 /7 FEE " 7 2C COMMONWEALTH OF MASSACHUSETTS Plc�l G � Board of Health, Y%i'2&Q t , MA. PP ATI FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT U - d Ab d () ❑Com Tete S tem ❑ Individual Com onents !!Q LU 7 z pplicanon or a Pert it to Const ct(}Repair( } pgta eO an on - p ys p Location "7 P Owner's Name Map/Parcel# Address Lot# Telephone# Installer's Name it Designer's Name ©i a Address A Jr f Address 7 wfiJ Telephone# 0 Telephone# 5 ®g ? .6 -'� 40iqa Type of Building Lot Size 191 LY©7 sq. ft. Dwelling - No, of Bedrooms o'Z Garbage grinder ( } Other - Type of Building No. of persons Showers( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) 110 gpd Calculated design flow 310 Design flow providedp 3 3D gpd Plait: Date 161,3116 Number of sheets I Revision Date 1119-3 ! Ki Title Description of Soil (s) _ Soil Evaluator Form No Name of Soil Evaluator M 1 4 r DESCRIPTION OF REPAIRS OR ALTERATIONS -o Q/v� of Evaluation 41 lag 116 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 th to in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ;V' , '✓ I Date /, ,? u �. j Inspections 2-0-17 OQ04A r/—W !;"A 1 A L/ .o W yL)P COMMONW-EALT14 OF MASSACHUSEW aLDE-0-00YZZ - Board of Health,VARA, MA. SI IDK off% I CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) 52/complete System The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired ( ), Upgraded ( ), Abandoned O :y by: at aLuwM_ a A 1" 75Yo has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated ��""�7Approved Design Flow (gpd) Installer t . Designer: -,W, Inspector: Date:' �.'- 1 — The issuancV of this permi shall not be construed as a.guarantee that the system will function as designed. No.IJ�1 C—' / " Z l4 2— FEE _ COMMONWEAN Of MASSACHUSETTS Board (f Health, Y+4 eN n Ln °W MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(A Repair( ) Upgrade L,) --Abandon ) an individual sewage disposal system at 'i r4,161 44 Qlk-A as described in the application for Disposal System Construction Permit No. ,Z.7- IZ , dated Provided: Construction shall be completed within th ar oNdate of this permit. All local coitions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date"��� '/ Z Board of Health