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HomeMy WebLinkAboutApp-Permit-ComplianceNo—1.7-16.0 .L-0 FEE J Jc COMMONWEALTH OF MASSAC14USETTS C, 4,,316 1 Board of Health, V]9-aM OVIA , MA. APPLICATION FOR DI O POSAL SYSTEM CONSTRUCTION ERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon - ❑ Complete System Individual Components Location O 2 C,4 mov Owner's Name Map/Parcel#D Address ��S S o V111% 'jvtj 5 j3us Lot# Telephone# 617— S/ 3— �,C a t Installer's Namecore J2AC �05-eC. ;00 Designer's Name. Address �. �dX l�{D� (� Address Telephone# go `Z o(:) I Telephone# Type of Building f1e:�Uo� Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other -Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS QS?•� t 4 -2 S Jf x � � k G� & � e>(0C)5R�� ;W4,C k !Ato CC)Ve The undersign es to ' t4:!!� vidual Sewage Disposal System in accordance with the provisions of TITLE 5 and further afire to o t e sl a Certificate of Compliance has been issued by the Board of Health. Signed Date 640-17 Inspections r�. No. / V i © FEE 00 CO's MONWEA1LT1 OF MASSACHUSETTS Board of Health, YaemamA , MA. .� CERTIFICATE Of COMPLIANCE COO -rA Ak Description of Work: /Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (/Upgraded ( ), Abandoned ( ) at `F O I l (;J, /ell 1110-41 - has been installed in accor ace with the provisions Qf 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. - % dated 7' . Approved Design Flow (gpd) Installer C, CC Designer: - Inspector: Date: c The issuance of this permit shall not be construed as a guarantee that the system will function as t designed.- No. C 9_ " I) C / N 5 p FEE `� 0 IJ COMMONWEALTH OF MASSACHUSETTS Board (f Health, VAR- j) 014 4 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(/Upgrade( ) Abandon( ) an indivddualge disposal system 0 as describ at e .. j rf . L ( �Gtf f7tt . . �' P el, n the application for Disposal System Construction Permit No. �7-1016 dated Provided: Construction shall be completed within three years of the date of this per it. All local conditions must be met. Form 1255 Rev: 5/96 A.M. Sulkin Co. Chakstmvn, MA Date ' r � ` /Board of Health L.441