HomeMy WebLinkAboutApp-Permit-ComplianceNo. Ba�Dc-!%�i3Z8 ��� lam%^�l/�.� FEEcJc��i. v
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OMMONWEALTH OF MASSACHUSETTS
Board of Health, — fZY�LO UJU MA.
P)0 ®N � ����0 SYSTEM CONSTRUCTION PERMIT
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?pplication for a Permit to Construct( Repair( Upgrade )AbandonO ❑Complete System Individual Components
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Location f V 1 H
Owner's Name ?N\A_ V �5 Q
Map/Parcel# �j / '� I
Address 5
Lot# i
Telephone# O
Installer's Name / � � C j�� j Cj
Designer's Name L -A N _ j L K);
Address ?y U 43 I 5 a -
Address) 'TiT, �, -- S.) N.J-DW
Telephone# S�Z) i�s' _,_5 Ot b 25-5--t
I Telephone# 't `` 1� -3 e15+-1
Type of Building J ] �� 'i A Ln )1 v Lot Size� dT � � � sq. ft.
Dwelling- No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)3 :5 ID gpd Calculated design flow Design flow provided 3 5 b gpd
Plait: Date i_ ! / t 1 Number of sheets L Revision Date '` A ,
Title S V� �� S SGl
Description of Soil (s) U . tr l ��`� �c i Z� S 3 <31�i 6 , 3 •�
Soil Evaluator Form No?- Name of Soil EvaluatorETR%L L � to of Evaluation +
DESCRIPTION OF REPAIRS ORAL ERATIONS � 7 �• �1 C� s, A5_ lob `� t g/X 1 + f
C V >^ CA C- -"+- ( �-I - ) 0
t
he undersigned agr s to ' t the ab described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
urther agrees to t o s to peration until a Certificate of o liance has been issued by the Board of Health.
igned Date 0-0-17
Inspections %� L/A /JL
Nall
i FEE 55,
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Board of Health, Y&R=mdLnn4 r -/P- S4
CERTIFICATE Of COMPLIANCE
Description of Work: individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
at� ��nd!) �U��-4%►��
has 'been`installe ilLjaccor ce with the provisions o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. !' f dated 77 ' ' Approved Design Flow 3 14 (gpd)
Installer C
Designer: L L Inspector: Date:
The�issuance of this permit shall not be construed as a gulvztle, that the system will function. as designed.
No.us.-''ir (� GAG? t l"i l.Hi FEE F: Ci 0
COMMONWEALTH OF MASSAC14USET TIS
Board of Health,Y P -M ®t��-PI, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (y) Abandon( ) an individual sewage disposal system
at 51- C 41E5 P? QRl>jN%f as described in the application for
Disposal System Construction Permit No. f dated
Provided: Construction shall be completed withinears o�tPi'e d`a�te of this permit All Ipcal conditions must be met.
f 10IM12/55 111:5!96 A.M`lull!,,111.IN11111 n,M1 Dattel [Booard of Ijealth
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