HomeMy WebLinkAboutApp-Permit-ComplianceNo. y/�+�V `� / - ;%^"6D T C,- C -4 - 6 Q c'/ � / _ � FEE X
17- 7 COMMONWEALTH OF MASSACHUSETTS &-ft05u-&
-` Board of Health,®u"M , MA.
ATION FOR. ➢DISPOSALS"TLM CONSTRUCTION PERMIT
A plication ibr a Permit to Construct(<) Repair( ) Upgrade /Abandon O-1,2f-CIrnplete System 0 Individual Components
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Location ) V1%'%C I OL -P LV
Owner's Name
KEQ
Map/Parcel# J Gj zq
Address
/�v-l-iCYc oP W .
Lot# _
Telephone#
sM �j 4 4 IS,
Installer's Name LLQ
Designer's Name. jDAd 4 5�&W^ /�
Address k)4c7
Address 1,5
SPE -)4R �,o" , 114 . I C 0
Telephone# S�? �L3 Z SS -6,57
Telephone#
SO,f 4 3 Z- Sr6,y
Type of Building 25/ PEAT VAC Lot Size 2 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons r Showers( ) , Cafeteria ( }
Other Fixtures
Design Flow (min. required) 440 gpd Calculated design flow 44-x/ Design flow provided gpd
Plan: Date 2-124112 Number of sheets 1 Revision Date
Title S l '% E l� / C 4 V of AI Dt0` GSW ai t6- DZLL% / G..L/
Description ofSoil (s) ``Tp S+VE)
Soil Evaluator Form No.
Name of Soil Evaluator 1) - 1'05 OV
Date of Evaluation 2rZZ / I
DESCRIPTION OF REPAIRS OR ALTERATIONS )-500 5 -or 17 a>< 30 S 0
j !v C -r/ -r7025• .
- heand ees to Inst above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agryes to of to th tem in operation until a Certificate of Compli nce has been issued by the Board of Health.
Signed Date
Inspections a-2 17 CbC SL`t (- - CJ(-
)- / 7 "" --o
se 12,
No. 14
'eel i °�'f FEE
Board of Health, VAR.MC)Qj, MA.
CERTIFICATE Of COMPLIANCE � Ic%~ C
Description of Work: 0 individual Component(s) Complete System GK
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedAbandoned( )
by:i'
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. w �"" dated 3 ';-2 `7 ' / Approved Design Flo f (gpd)
Installer T) A O A
Designer: -�; SP44� Inspector: I Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 'C? E �i .� Ul�;a.. FEE�-7 COMMONWEALTH OF MASSACHUSETTS J,,*
Board cf Health,� 0% M+ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade A Abandon( ) an individual sewage disposal system
at 22
1
�4 i ,/( uO _ as described in the application for
Disposal System Construction Permit No. ii �7 ,dated —% "%
Provided: Construction shall be completed within 4we8(?eWof the date of this permAll local conditions must be met.
f`� y� oard of Health
Form 1255'. Rev, 5/96 A.M. Sulkin Co. Chadesfown, � Date.. � / �
r"-.^ // -1-.r /�r ?0 r'J _41)..// 111 �.�A/� � ? !%�1s d ,�i_ -lie '� G.'o.�