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HomeMy WebLinkAboutDOC001No. Co1-3 17 I � '- BLD -jV, - r ! - 0 510 FEE J•�D 74f ,,fir, V" ! AU11VRTf� Board of Health, ✓ W MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System .0'Individual Components Location 4 q 3 -SeT (jA Owner's Name N + SAk) CRoMt w Map/Parcel# M A? j G - 0.2- 5 Address 153 ONZ Lot# z Telephone# Installer's Name QA . W !D E C i !SES Designer's Name. ZijC--dij Address 1,53(26 Address -t,) ��(- Ef Telephone# 50,ik -L0,1 Telephone# Type of Building PEs l* EOT10 -(, Lot Size TO ( 3 sq. ft. Dwelling- No. of Bedrooms -3 Garbage grinder ( ) Other - Type of Building No. of persons Showers( ) , Cafeteria Other Fixtures Design Flow (min. q - n. required) 333 gpd Calculated design flow Design flow provided 39, 7_ gpd 4 Plan: Date 3 - ?z 1 ,,N��u��mbi�rr of sheets -� A , P- Revision Date Title 193 SCTu6kI�or L s)6 TJ"t�4'lo( -n-4Pop--r Description of Soil (s) di Gi t o m. SAO) (&-R! 9 "f ! 15 (5-C MtJ Soil Evaluator Form No. Name of Soil Evaluator R K? (fbjYC-:76 Date of Evaluation S -fig DESCRIPTION OF REPAIRS OR ALTERATIONS LSC N)t✓ iJ H- ©4-1�50)C ,7 Q-ACe .OM P -;L<) e, et�tyEr� m4�ez� Qjj 4 �� of- ���.� � �St�1zRcZya.Ji�t1�3F,�•• 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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed_ Date Inspections FEE ®1"AUrN �YVLTjt�t ® .1°llSlLJ ye Board of Health, YARi M4 MA. CERTIFICATE Of COMPLIANCE e Description of Work: eIndiv dual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded/Abandoned ( ) by:,��C�! Upgraded/ Abandoned 5Wt,*C<1eE!r V -0Q6 has been installed in acc dance with the provisi ns of 310 CMR 15.00 (Title 5) and the approved design /p ans/ass uilt pla ( application No. f �' dated% / % Approved Design Flow -� (gpd) `'M, Yi Installer MEWME 74— Designer: il1Cw111r= Wbttt'AX Inspector: Date: The issuance of this permit shall not be construed as a guar ee that the system will function as designed. No. 6' 01-1)(—Gidlp"IDL COMMONWEALT14 OF MASSAC14USET TS Board of Health, Y�,df%%}f , MA. DISPOSAL. SYSTEM CONSTRUCTION PERMIT FEE CCk4V2 Permission is hereby granted to; Construct( ) Repair( ) Upgrade{,, Abandon( ) an individual sewage disposal system at 1 9� �-ro Lj<EC 7 ^-&:*,1 as described in the application for Disposal S stem Construction Permit No. dated Y Provided: Construction shall be completed within i6ks of�e date of this per it.�All local condi 'ons must be met. Form 1255 Rev. 5/96 A.M. SPA C„ o. chadeslowo,MA Date//Z1. '/ Board of Health