HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0)A DC -C7 33 41
C®MMONWE1OF MASSACHUSETTS
HLTHDEPTSYaEAT
Board of Health, 1 1s46 ROUTE?8 , MA.
APPLICATION FOP, DISPO�V?RMAMCTI®N
FEE 66Y, 00
0
FEB 2
D n
Application for a Permit to Construct( ) Repair()( Upgrade( ) Abandon( ) - ❑ Complete System klnc dual Components
Location l 11,9 CJ4CC A
S rlZ
Owner's Name F!>C*4MCb{C-- VAISL,e,
Map/Parcel# M84j1 j X15
S.3
Address 178 C—(GEER/ Si' Y%kftpv70.,� 7>0yt.'j
Lot#
Telephone#
Installer's Name (2AA& --)tQ,C
EAJ-76kf 41SFS
Designer's Name &1/4
Address , S Cdr `
m4-5l4peg
Address
Telephone# 509 - 1 f 7 Z _ 2:9-7 '?
Telephone#
Type of Building R —6 l Z) 6107 1 A- L, Lot Size 1 � q.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided gpd
Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 'W?L -0 uP6 PA004 TA+J4- TV (60C
TrJ � c�ptc� IUFiZci D - i3a� ccJ t -�r4- iZ i Si��
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no=tace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date-,Xq-04-00
Inspections
No.� C)o
I
FEE f�
COMMON ����]"EALT14 Of MASSAC14USETTS C" Z
Board of Health, I A P-twow—V _,Am.
CERTIFICATE Of COMPLIANCE �,�tQ ��s'
Description of Work: Y-4ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (�andoned ( )
by: QN C- Lj (D r= C—a1 7(5e PQI S ES
at 178 C-iz oe-7j 5Tgez=- '
has been installed in a_ccsr nce with the provision of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. % 7 , dated Z" / Approved Design Flow ..----- (gpd)
Installer
Designer:.' N/A Inspector:
The issuance of this permit shall not be construed as a guara
No. �.��NDC 17^.5. (qCKP W1"DC-- FEE t J"'• UV
7- COMMONWEALT14 OF MASSAC14USETTS
Board of Health, YC acJ %?q MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(% Upgrade( ) Abandon(
at 17 8 &, I Lzo
Disposal System Construction Permit No. % 7- , dated //
an individual sewage disposal system'
as described in the application for
Provided: Construction shall be completed within three years of the date of this pe it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date /7 Board of Health
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