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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE �V V�0 boltDc.C MMONWEAICTR OF MASSAC14USETTS � W � 11 Board of Health, �� PUVj,QX}`U , MA. AP ATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) UpgradekAbandon( ) - ❑ Complete System ❑ Individual Components Location it hoe -nu -R--, Owner's Name:a � t Map/Parcel# 33 7 TY Address V 33 ,T1 -j-% D Lot# Telephone# Installer's NaTeTY)ML�MJQ2, Designer's Name' 0 Address 3 - E 4 Address Iy Ma iolsk, q Telephone# Telephone# Type of Building i CY�f)�ln Dwelling - No, of Bedrooms Other -Type of Building No. of persons Lot Size sq. ft. Garbage grinder( ) Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 330 gpd Calculated design flow Design flow provided gpd Plait: Date jQ I q) Q01 (O Number of sheets Revision Date Title _ 1 er Description of Soil (s) cJ Soil Evaluator Form No. �-1 V Name of Soil Evaluatorlk2� �� Date of Evaluation A) & 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 pIV4 the system in oration until a Certificate of Compliance has been issued by the Board of Health. Signed �Y .r 1 i Date r --r Inspections � f L � $' No,; i�at�9 Di-� �7-3 (o-� etiwcs�C' / fRkl EE t� .3 .zl Board of Health, , MA. ;61G 0Q/0-7/1-2 f CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedk), Abandoned ( ) by:, 1.1 tY l �.©.ri-i-�°r�,y; s at It has been insttalle in accordance with the provisions of 310 CMR 15.00 (Title 5) and the appro ed design plans/as-built plans relating to application No. dated '� p Approved Design Flow-gpd) Installer 0 na-J:Mc:b t IC 0 ; Designer.�` 11..x, �.(,. �t� � Inspector: Date: �i ''- The issuance of this permit shall not be construed as a guard a that the system will function as designed. No.}�-��`j ��.. C. Q� i ��^� UrK'� FEE__ COMMONWEALTH Of MASSACHUSET TIS G ke, 101-7-9 Board of Health, �I '. 0k MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby gran/ted to; Construct( ) Repair( ) Upgrade (L, Abandon( ) an individual sewage disposal system at f j 01% CN V e< l t rP as described in the application for Disposal System Construction Permit No.� , dated Provided: Construction shall be completed within ti i' e; date of this per t. All local conditions must be met. / Form 1255- Rev. 5/96 A.M. Sulkin Co, chadeslown, Mau+ ,r^ Date _ " %/ pard of Health _4,xol f /