HomeMy WebLinkAboutApp-Permit-ComplianceNo. �(JiJ V FEE 46-157,0 0
b 0ODC-r-38 6 6 COMMONWEALTH LTH Of MASSACHUSETTS C"u��� a
Board of Health, ) Q1n]A MA.
L rr LI�ATI�N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
pphcauon fora mit to ConstructO Repair ) Up de Aba don O Complete System ❑ Individual Components
,,ja �
Location /-
91 V
Owner's Name Q
Map/Parcel#
10
Address I al) i 65SADn Q Q3 2 -
Lot#
Telephone# & I % -a 9� d
Installer's Name4t
cn-�L S
Designer's Name n , j taC,
Address 3
G E lA
AddressQ0 p)_ inn p `
Telephone# 6-2) —
Telephone# --7.75
Type of Building Iles! Lot Size sq. ft.
Dwelling - No. of Bedrooms � 1 k Garbage grinder( )
Other -Type of Building ` r s Showers ( } , Cafeteria ( )
Other Fixtures
Design Flow (`mina required) 12-10 gpd Calculated design flow Design flow provided gpd
Plan: Date oZ ` �.' Number of sheets Revision Date
Title !:�Glra V 0 m e °t- 0 0,0 1 d- a hb i rns
Description of:Soil (s) extroe-C cy0 f;E� 5OCA tA
Soil Evaluator Form No. Name of Soil Evaluator PW JJ &l-1 [(QDate of Evaluation i 1 D-0 ! ,
DESCRIPTIONPF REPAIRS OR ALTERATIONS I ��
��f�•° l' C� �� � ,i ;�,? �t � � _x.75" �'t�� :.fir
Tb�undersigned agrees to inspall the above des J ibed Iddividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pla¢l�te��ortion until a Certificate of Compliance has been issued by the Board of Health.
Signed (' r Date 3' 3 1) Do t -�
01
Inspections
No.
COMMONWEALTH OF MASSACHUSETTS -�� FEE
�� �' _�
die
Board of Health, V)(LY1l j)j MA , MA.
CERTIFICATE OF, COMPLIANCE
Description of Work: ❑ Individual Component(s) kQ-4 oo5niplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( A ndoned ( )
0-1
by:
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the ap •oved design plans/as-built plans relating to
application No. dated ` %t� 7. Approved Design Flow (gpd)
installer ' 1 N \ "
Designer: l�n,�"'i Co A ! ! A C- _ Inspector: Date:
The issuance of this permit shall not be construed as a guaragt a that the system will function as designed.
No. FEE, V,
COMMONWEALTH OF MASSACHUSETTS C lO-3 70
Board of Health, M D t,MMA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( Abandon( ) an individual sewage disposal system
at I'%) k r - as described to the application for
Disposal System Construction Permit No./_, dated 'r '''f�
Provided: Construction shall be completed within ar of"the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA � ,�^^ Date,4 Board of Health � r �