HomeMy WebLinkAboutApp-Permit-ComplianceNo. r 1! - /,7-,-7- �/ 9 c � YJ ` v ` 0 ( FEE _
COMMONWEALTH OF MASSACHUSETTS �7
Board of Health, �a'�►^'�d ` t A, , MA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgradeg Abandon( ) - 4Complete System ❑ Individual Components
Location 1117 H, 46a-1 k /2 Sa
Owner's Name M,CvNcf-e ` ju 2�S
Map/Parcel# 9(y —/0 7
Address 4-7p` o� -
Lot#
Telephone# �i3 3(v -q asS
Installer's Name ` t `Z,L
Qi
Designer's Name
Address C)
Address i`L W , CIYtSS.(-'-, 4' 1ej TW T:" �- Cltc
Telephone#�j 3�e f'�-��
Telephone# cf-g_
Type of Building �ZeSeo6k fia .�t�n`t� h /tet►k �l y Lot Size 13 <-%O sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) �3® gpd Calculated design flow
Plan: Date 170-311(1 Number of sh/eets Z
Title
Description ofSoil (s) f%
Soil Evaluator Form No. _
Name of Soil Evaluator
Design flow provided 9:M ./ gpd
Revision Date/
I Z
Gt iz G< ,
-02 <2
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS 7U� : -C II
c Ch4'M4t�' &J/
The undersigned agrees to installaboveseribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to rtfm oppration until a Certificate of Compliance has been issued by the Board of Health.
Signed --�� Date /-27
No. rr3V 7- .. COMMONWEALTH OFMASSACHUSETTSF/EE ';-5-f7
Board of Health, `,:► V'McoJ �A
CE TIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) AS Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( 6andoned ( )
at / �ITrV 4V'AQ( t"
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the app oved design plans/as-built plans relating to
application yNo. ,dated- f—,/ Approved Design Flow (gpd)
Installer, m �° o v✓ 4� 1 �O°� / t
Designer:�4 ��` e9> Inspector: � L�! %�i Date: �" f
The issuance of this permit shall not be construed as a guaragtee that the system will function as designed.
No. i,7 -, 7, 2 f! FEE _G
2 C:- COMMONWEALTH OF MASSACHUSETTS 11IJ-111"e-.71 7,7
Board of Health, Ygn f rpt rn) j=:b7 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repair( ) Upgrade (#) Abandon( ) an individual sewage disposal system
at f� 7 14, Ski is -LA 9d �r . VA <'m 00,f-� as described in the application for
Disposal System Construction Permit No. ! dated�j "
Provided: Construction shall be completed within thre oog�e date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date / -)7 pard of Health