HomeMy WebLinkAboutApp-Permit-ComplianceNo. V C—� 7 �3 �ZO + �%C�� ! K- I/
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DIr�
-elllc mMONFLTW14 OF MASSACH�Sl TS
Board of Health, `!J_ll , MA.IIR
APPLICATION FOR DISPOSAL SYSTEM CONSTRIJ�T�� PEP�
Application for Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑ Complete S st ❑ Individual Components
A h114)
Location
Owner's Name *A crib U,; 13Y"C\t_*x
Map/Parcel# i
Address ts3 gal \
Lot# e
Telephone#
Installer's Name►(per SS two
Designer's Name eL6 -V>
Address
OZ6LkqAddress
i5 C-mb a. -_ti S,d 5 w`
Telephone#
Telephone# •Soo
.1.33
Type of Building
L— Lot Size q49 sq. ft. f
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) 753 O gpd Calculated design flow �Q ,�_ Design flow provided t- O gpd
Plan: Date a\ kZ.\ t'1 Number of sheets Revision Date
Title P G"'ZI
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 2-At&C C 1>^V1Qt1 j' GNS r
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 &Ystem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
FEE
COMMONWEALTH OF MASSACHUSETT a c" a.7 %9
Board of Health, VAj)tM4 , MA.
CERTIFICATE or COMPLIANCE
Description of Work; A Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (y), Upgraded ( ), Abandoned ( )
by: ( ,wn. � v� r \? G °� L .� `'fie oto \ r, Vt -,N61- 11'T' Qn312Z
at
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 f
application No. �^'� �, dated !w �� Approved Design Flow (gpd)
Installer vrr
Designer: $ Cr> - 'C -e c ,r., Inspector: Date: %4/
The issuance of this permit shall not be construed as a guarantthat the system will function as designed.
No. ,+f C_�' t��1 !`y \;C �/` _"� Ff�=Si{_ [t C9 ( FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, O ( , MA.
DISPOSAL S1TSTEM CONSTRUCTIONPERMIT
Permission is herebygranted to; Construct( ) Repair(,) Upgrade( ) Abandon( ') an individual sewage disposal system
at—o `1. f ^ s, .- =;t i t' , V 7— as described in the application for
Disposal System Construction Permit No. , dated f�= -7
Provided: Construction shall be completed within 4,4r- �+�rs oFthe date of this permit. All local conditions must be met.
Form 1255' Rev, 5196 A.M. Sulkin Co. Chzdestawn,Mti Date`'ffoard of Health `zaz r