HomeMy WebLinkAboutApp-Permit-ComplianceNo. e> O DC^1 7 33V1 bL-0 7 FEE
% ;7 COMMONWEALTH �L4�&N&FTS d&4uj6
YARM
Board of Health, 1146 ROUTE 28 MA. 15ZA
�8�2111
APPLICATION FOP, DISPOMMM STRUCTION PERMIT
Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
4 R t-= V e-
Owner's Name OAiJ ie- L 8 (.t reg l,.A eW 1 we
Map/Parcel#
Pk CCL _T_� 99-16-1k
Address Rt -r,6 Av _ 5 u,zo YAPjcornA
Lot#
53A
Telephone#
Installer's Name �, �A -
Designer's Name
Addresst
,
Address �� W. Q�0SSV1W Iia �6Z2G�iD�4t.��
Telephone#
6 .. �� -1
Telephone# 50g - q 7Z - 5 3 ( 5
Type of Building RG5 1 A G&) -T I A.L. Lot Size 10 00 40 sq. ft.
Dwelling - No. of Bedrooms 4 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 4L4I9 gpd Calculated design flow
Plan: Date a - 14 ad 11 Number of sheets oP,
Title io (o PLI T -A AVC S O VT� YAR1-' L)-rf'1
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided 45; 4.41 gpd
Revision Date
Name of Soil Evaluator Pa W, E1JTEE Date of Evaluation :;L ". 9 - D..O i %
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 Compliance has been issued by the Board of Health.
Signed C Date
Inspections
C
AV
COMMOLTH OF [ASS -C14 S TTS J�
.. Board of Health, Y+P.MOC.i�'Y'( MA.
CERTIFICATE OF COMPLIANCE
LIANCE
h•Description of Work:. ❑ Individual Component(s) ❑ Complete SystemvX
The.undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (A, Upgraded (.), Abandoned
:. by. C-LAP6wt-G- Gk)--Etpra.Isr"t
at 4a(..1Z t:TRI 400_ S6 ?
has-been installed in accor ,artc,with the p ovist ns`of 3 CMR 15.00 (Title 5).and thea pro ed, design plans/as-built plansrelating to
application No. _1 dated ' /Approved Design Flow �- gpd)
Installer CAllam E Gd:lTG-Ay t15 _
Designer: CLEC-Wx ,b 910& WiDZU4S Inspector: / Date: _3
The issuance of this permit shall not be construed as'a guartfee that the system will function as designed.
--- No. ` i)" A A) C_^'"( � ""�� t�''.-l"' - -- � � � - FEEj:%011
0Q
COMMONWEALTH OF MASSACHUSETTS
Board of Health,: ,/��f� D UTI- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repair (x) Upgrade( ) Abandon( ). an individual sewage disposal system
at (a ` i -rA, Ave as described in the application for
-
Disposal System Construction Permit No. / , dated
Provided: Construction shall be completed withi ars of the date of this permAll local conditions must be met.
' !
Form 1255 Rev. 5/96 A;M. salkin Co. Boston, MA Date lard of Health
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