HomeMy WebLinkAboutApp-Permit-ComplianceNo.
--3 877 � V - .off
C®MM®NWEALM Of MASSACHUSETTS 3533
Board of Health, , a _ 'NSG 1, q , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repai'pgrade( ) Abandon( ) ❑ Complete System, knd�ividual Components
Location
Owner's Name
AACI1
Map/Parcel# qs
Address G
�>er� ✓ds� �'�yre
Lot#
Telephone#
51 -)'7 -4106'01
Installer's NameKV- ����� J. �,
Designer's Name.
S'UI<r �Svrr 1n Pri1✓�
-4
AddressPO 7 S �� ate,
Address
Telephone# ,%21%-6 JCi_ VV)
Telephone# _5-o
, �•.
Type of Building �rSFr��.� j �+ Lot Size 901 d-0 sq. ft.
Dwelling - No. of Bedrooms �h JYc�� Garbage grinder( }
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. •equir d) 33 a gpd Calculated sign flow, 330 Design flow provided' ® gpd
Plait Date 103 ) UI Number of sheets Revision Date 4,1L
Title
Description of Soils) tt 1Gy,5
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS rS dl ? Gn TAS)-
l9 bcr�o�i� P��'S�►i��, L ���► �� ��
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 o place the system in operation until a Certificate of C mpl'ance has been issued by the Board of Health.
Signed -====7 / Date q I O %
,
t,
Inspections
No. 664 IDC. "' 1-7 "..3977 C MNWEALT14 OF C USETTS FEE k5s,-00_
Board of Health, n QDA , MA.
CERTIFICATE Of COMPLIANCE
Description of Work; dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), RepaireZ14--�, Upgraded ( ), Abandoned O
by:e.f
at
has been installed in actr ante with the rovis'o}}ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated 4 .G- 7 Approved Design Flow 4X11 (gpd)
Installer �. K+e c r.. i 1 V-! . -) _-- -
Designer: C, Ler):!kr ie;gae-.q Inspector:
The issuance of this permit shall not be construed as a guars
Date:
that the system will function as designed.
/ COMMON WEALTH OF MASSACHUSETTS
Board of Health,) ()_, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
e -
FEE , 0-0
k-;0_3533
Permission is hereby granted to; Construct( ) Repair-410-1iUpgrade ( ) Abandon( ) an individual sewage disposal system
at loa ) 5 Ire- as described in the application for
Disposal System Construction Permit No. P , dated � f). /7
Provided: Construction shall be completed within 4405a�sthe date of this per 't. 1 local condi ons must be met.
Form 1255 Rev: 5/96 A.M. Sulkin Co. ChatleslaNn, MA Date f �f Board of Health