HomeMy WebLinkAboutApp-Permit-Compliance6No. v / _ / U / C % + / �"' O� FEET%
COMMONWEALTH ®f �ASSAC14USETTSof
YARNUCUTH HEALTH DEPT.
Board of Health, c OAI ITC MA.
APPLICATION FOR DISPOft1'MRMUCTI®N PERMIT Aw�
Application for a Permit to Construct (pol"'Repair ( ) Upgrade( ) Abandon( ) - ❑ Complete System Q Individual Components
Location j ` j `.
Owner's Name _
Map/Parcel#
Address r C
Lot#
i
Telephone#
Installer'sName
Designer's Name
Address 14
Address
Telephone# e- 0
Telephone# ✓N✓c'�
Owe,
Type of Building & S i4 #& 14Q - Lot Size ` !F gra sq. ft.
Dwelling - No. of Bedrooms 'T&O C Garbage grinder ( 0
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) ZZo gpd Calculated design flow _ Design flow provided Z4 gpd
Plan: Date Z " /Z - D 7 Number of sheets Revision Date
Title
Description of Soil (s) n - 2F d "d4 _tA-41J /1j f-% � �bR 1//4P
Soil Evaluator Form No. Name of Soil Evaluator p�i �'� fl /l Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 to place a tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date :3 '-A(^ O
�y
Inspections
No.
COMMONWEALTH Of MASSACHUSETTS,'. P"A�JEE a_
Board of Health, MA.
CERTIFICAiE' OF COMPLIANCE
Description of Work: B'Individual Component(s) ❑ Complete System Jk
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned () ,
by: Li t • k, 5.51 r ,) r
at m LC _d a ) ZWA641: k,tj y r
has been installed in accordWce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. d7- 7O ,dated 3 16 /V,�Approved Design Flow pd)
Installer � . r k �l �i � //� A/4�
Designer: Tb ,� ('�) dell y c Inspector: Leo (/c.2 L1-41 Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 0 ? ZOb C/
COMMONWEALTH Of MASSACHUSETTS
Board of Health, , MA.
DISPOSAL SYS C®NSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( (/)--Repair
at SY7 -:5-, J,/. ) Z .fifes` A „ /r,1 w . ►/
— -i
FEE SC e?c�i
) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. Q %- 7� dated�� -� r
Provided: Construction shall be completed within �V r o the date of this permit- All local conditions must be met.
Form 125r5 v. 5/9��6//A.M. Sulkin o. Boston, MA Date? `/ yr 7 Board/ of Health C -