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HomeMy WebLinkAboutApp-Permit-ComplianceNo. B D�C� (^� FEE i0 COMMONWEALTH Of MASSACHUSETTS Board of Health, ! 6 UJ , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade�andon ( ) Complete System ❑ Individual Components Location 68 1(1017-1;2d Owner's Name /W 41Z - e-- X),,;;'IV d,4 Map/Parcel# ,%-j `"'o Address vez—, ye _ Lot# Telephone# =gyp Installer's Name C�: �� Designer's Name 2c&,vk ko' Aw Se/j�2AII&4 WAQ ' Address �,� Lc%!/�Pa+i Address % , j-O.��,; j� o�eidlA4( �',/ Telephone# ��-*� Telephone#©gam -- P 3 7,9 Type of Building Dwelling - No. of Bedrooms Other -Type of Building 44-A Other Fixtures Lot Size 1,�6762-9'•'v sq. ft. s Garbage grinder No. of persons Showers( ), Cafeteria ( ) Design Flow (min. required).�gpd Calculated design flow Plan Date .S /R-- Z7 Number of sheets Title Design flow provided' 1 gpd Revision Date Description of Soil(s) "50,t C Z --- Soil Evaluator Form No. ; Name of Soil DESCRIPTION OF REPAIRS OR ALTERATIONS �` ✓ '09A The undersigned agrees to ' the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to ce ' ystem oper 'o til a Certificate of Compliance has been issued by the Board of Health. Signed Date `' Z-3-'/1 Inspections A .i. M No. a. (A D C -1-7-4-2-0-7 �t� �i��'.�/ ���gFEE J �: COMMONWEALTH OF MASSACHUSETTS C (4 L (,a ! Board of Health, MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) C1 -Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedu�- ;'Abandoned by: P 11 l� j c`s'I i E"S co ., 5� has been installed in accordance with throvisions 310 CMR 15.00 (Title 5) an the a proved design plans/as-built plans relating to application No. dated f . Approved Design Flow (gpd) Installer S 8 E 0 f �4 CC k) 5)-. r / F Designer: JPryir-�f Inspector:�thallt t Date: The issuance of this permit shall not be construed as a guar he system will function as designed. No, OLLA FEE � G i �i-- /° i f COMMONWEALTH OF MASSACHUSETTS 3(0�(o Board of Health, YA&Md 07-1t MA. DISPOSAL. SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct( ) Repair( ) Upgrade (-- Abandon ( ) an individual sewage disposal system at o (z o n l} t4i d yj (C. /-,l f'J (J ° 1 /hAescribed in the application for Disposal System Construction Permit No.. ��' dated' ��i` 7 �ears o Provided: Construction shall be completed within wef the date of this per 't. Vocal conditions must be met. Form 1255Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA : ;i Date b !� 7- / 7 Board of Health 1