HomeMy WebLinkAboutApp-Permit-Compliance`Ta
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TH Of MASSAC14USETTS
r r� MA
Board of,Health,�i�i® l- , MA • t. r
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI�O �
(, L, Permit to Construct( Repair( Upgrade �bandon( - ❑Complete System dividual Components
Location 3f- M p,'1—(,q V 1r %Z-
Owner's Names_'a--(I- (j?1-LtVCLZ
Map/Parcel# 9'?/ i
Address �t( /ti Uti7 t`C V2.
Lot#N
Telephone# 5-03 j�7 8'62
Installer's Name - 'PEA16 , l ,,V b(;,q A-lI/v � L L(
Designer's Name bAN ^
Address , S 5904'1< UN -1 h4%GJ I Com►
Address 15,
Telephone# p' q -3Z S7�,(',5
Telephone# <- 4-U—<3-65 ,
Type of Building DLAA -Q','J - Lot Size IS, 632 sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder( )
Other- Type of Building r No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 2-537--7, Design flow provided &95-7 gpd
Plan: Date ?-17Z 17 Number of sheets 9 Revision Date
Title 51 (E � � ��d C f1 Ajx7 vC% 1 C)N)
Description ofSoil (s) S PUa�
Soil Evaluator Form No. Name of Soil Evaluator b4vE r-'-qSUA- Date of Evaluation 21le, 1 1%
DESCRIPTION OF REPAIRS OR ALTERATIONS 6 -F -S45 OF 4 Lf� 3 o SO 11Vf 1 L7W,9-7U2 U Al t -8.
The and agrees to Inst above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of top e e tem in operation until a Certificate of Complianc has been issued by the Board of Health.
A � lr r-i� `7
Signed e r Date
/e
c :Inspections �--=$n4
No. —5750
COMMONWEA1LT14 OF MASSAC14USETTS
Board of Health, , MA. f
CERTIFICATE Of COMPLIANCE _
Description of Work: ❑ Individual Component(s) ❑ Complete System'
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at AA
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector: ! t Date:
The issuance of this permit shall
not be construed as a guar tee at the system will function as designed.
No.i f--` E"*!.� c. J —� �' J 0 (C9 FEE✓ l
COMMONWEALTH Of MASSACHUSETTS
Board of Health, 1&0M t r 13. MA.
F.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gran ted to; Construct( ) Repair( ) Upgrade(- ')kbandon( ) an individual sewage disposal system
at ' ` C ` �''` r - . �_'i' , t as described in the application for
Disposal System Construction Permit No. - >' dated b
Provided: Construction shall be completed within t4=J,1-6 f'tlie'Fdate of zhi®roit. All loc onditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date ja —` Board of Health