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HomeMy WebLinkAboutApp-Permit-ComplianceNo. b"-1X4r--V7 7 /3 / o ffl --1 `7 - 00aV 3 0 / 6 �/ -2,7 COMMONWEALTH Of MASSACHUSETTS FEE 55—,00 3ssS f Board of Health, 64:gM l , MA. APPLICATION FOR DISPOSAL SYSTEM T UCTI0N PERMIT Application fora Permit to Construct( ) Repair( ) Upgrade Abandon( ) - Complete System ❑Individual Components Location � z� / Q /l A.lt'b1 Owner's Name Map/Parcel# © Address Lot# Telephone# Installer's Name ��--'�j� `ter 8/Lr,7s _ Designer's NameZ1A1kA10 A) S�wICR,o Address, Address `� C> (�jok G f �� s'p 0zj,,vj t Telephone# !�2 Telephone# SO g-- -- S> 3 ? Type of BuildingSze. 8 sq. ft. Dwelling - No. of Bedrooms Garbage grinder M7 Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided 3�5l gpd Plan: Date /O- l Z `�6 Number of sheets Y. RevisUn Date Title/V i(i �� �/� jaO.t�G.[lf /i -f -1`d l' S.�7 Description of Soil (s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of 1,4zl Date of Evaluation Gv — The undersigned agree o ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to plac e s �n oa ertificate of /Compliance has been issued by the Board of Health. Signed Date �! '� Z Inspections FEE: t�} COMMONWEALTH OF MASSAC14USETTS Board of Health, Y&eMOLYTY , MA. If k CERTI� Of COMPLIANCE P P Descri tion of Work: ❑ Individual Com onent(s) Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade Abandoned ( ) has been installed in acc rd nce w4h the rovis application No. AtI, dated Installer Designer: ZG'.<1IILr A�k 7:z!.U0r, Theissua nce of this permit shall not be con411-11f 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to /�. Approved Design Flow (gpd) Inspector: as a Lruara Date: 17 e that the system will function as designed. r, COMMONWEALTH OF MASSACHUSETTS Board Ac f Health, �r� �/ n (M4 , MA. ������ ll. S1 (f CONSTRUCTION PERMIT FEE._ Permission is hereby granted to; Construct( ) Repair( ) Upgrades(bandon ( } anindividual sewage disposal system at f- 14 as described in the application for Disposal System Construction Permit No 1 ated >- Provided: Construction shall be completed within tsb @e yezcrsOe *of , ate f thpermAll local co Iditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date). `l ,� Board of Health