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HomeMy WebLinkAboutApp-Permit-Compliance:d No. 661�DC�f�-3Sy5 r _L -7 o 0 4 3 TT A -,COMMONWEALTH OF MASSACHUSETTS MA ik 0 2 Board of Health, , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION Application for a Permit to Construct( Repair( Upgrade(_' Abandon( - ❑ Complete Components Location qq shfl-le'- Owner's Name ek Map/Parcel# 'a -G Address Lot# Telephone# SC `7 _ Installer's NameDesigner's ^' 6 Name y� S B07/d Address kn Address Telephone# il ,O (o Telephone# Type of Building Lot Size I 0 sq. ft. Dwelling - No. of Bedrooms 2— 1:�: l 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 Plain: Date Number of sheets Revision Date Title Description of Soil (s) cS-enc° Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS'_IP,AO Thede rsigned a es to A tall the above des 'bed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees of to a the tem ' o " ntil a Certificate of Compliance has been issued by the Board of Health. Signed / Date �_� o -_ 0 ��""*`7 . 1 • //J FEE ``s. `�hJ COMMONW-EALT14®f MASSACHUSETTS Board of Health,MA. t CERTIFICATE Of COM LIANA C -, Description of Work; dividual Component(s) ❑ Complete System I- 41-;� le- The CThe undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (� dA andoned O ,p' 7~" e has been installed in acc�dpance with the provisions of $40 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. it dated /T Y 4 Approved Design Flow° ;(gpd) Installer 11 i r G2i) ►i -v _t. Cc C k:_nQ P a.,LA q Designer: ri ¢� 1 SOY--��{ =�e Inspecti`°�+'`'�. Date: The issuance of this permit shall not be construed as a guarantee that the.system will function as designed. _. No. -1 f 1-7 C_,(,, FEE _ o 4 d COM ©NWEALT14 OF MASSACHUSETTS Ck4 12 @13 Board of Health, , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at Gt �% ! t as described in the application for d A Disposal System Construction Permit No. /, dated ���,,�[�) Provided: Construction shall be completed within s�E`tlie''ate of this �tfnn` All location tions must be met. m�Form 1255' Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date j� Board of Health c -