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HomeMy WebLinkAboutApp-Permit-Compliancer• � No. 60�DC— Vo-- �%� .� /� ;, yFEE > �''r��� °CS Z 1 CO�[�''1 ONWEA .T ®1 �(ASISA/ 'USETTS ' Board of Health, A 2r�i0 i , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT App 'cati( on for a Permit to ConstructRepair(►4pgradeO Abandon(- El�d Complete System ividual Components l., L cation 9 6 I N Owner's Name � �cJ ✓rr y f ��y ap/Parcel# 2 �j ? 3 % Address 9e f1XAW,,[ w LtJ Lot# Telephone# 727- Installer's Name ��i f�� ���✓ �7—n/< Designer's Name. f0,V,.t_e Address 10o- ,To X /.- l v S Address y0p . 91,,V a s! A Telephone# 7y7- %7,07 Telephone# 77J"- f 76 6 Type of Building 1( e_ode Aa t A4, Lot Size %� � d 7 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 Plait: Date %�ZF� /ti 1 Tzmberofsheets Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Cv n,j*--e-% -eX,'r h r� ���� C �y ✓ n/ aw ✓ Ao v_ 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 •pz -Z Inspections No. 014 0C -16 —0 I 7 5 ° c nC" FEE S2Z.06 CO'l[[MONWFA1LT14 OF MASSACIIUSETTS/7 /,3 :3 7- Board of Health, t YVH_—, MA. / CERTIFICATE Of COMPLIANCE'^ r! ' v +�, P P () PSystemlei (�+f�G�() tJ % Descri tion of Work: Individual Com onent s ❑Com lete ThAindersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded�A:radoned ( ) by: - lUla,--/rr.) {4'-:rre,Rn.• -7--�jr- at y ' ! s.R c/. , .4 14) iR.11i / has been installed in acco(a da e with the rovisions of 33 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.dated " f 4a . Approved Design Flow (gpd) Installer r 14✓r. -7 Designer: i'�rr,W�? s r �l t. Inspector: Date: 7 L The issuance of this permit shall not be construed as a guara,4 that the system will function as designed. No. C �(o U�i� ( Ff Irr'r-�J L.A A) D S C-Pr P INtS FEE Board c f Health, 'N/Ae M a .i t"i" + , MA.. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(V / Upgrade( ) Abandon( ) an individual sewage disposal system at e Z. .i jp Lt1 '� Y. as described in the application for bis osal System Construction Perm / f p y it No/�•,-, ��� , dated Provided: Construction shall be completed within t trgg_years of the date of this permit.,All local conditions must be met. '` Form 1255' Rev, 5/96 A.M. Sulkin Co. Chadestun,MA Date=� .� ' Boardlofflo alth > .' �✓