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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1301A1DC-I"7-(f,?,37 ��'(C%' " L�� FEE 5' COMMONWEALTH OF MASSACHUSETTS R LE 0 " `E: I V E7 jr ©Q� 1 Board of Health, &9*/.b , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION EkV 077 ID App ication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑ Complete System 0 Individual Components Gzhnrl 14 L cation 1 � Owner's Name Map/Parcel# �� Address i l Lot# Telephone# S( Lt q (1a Installer's Name ` r_',IA4C Designer's Name c V Addressa I s Address -n ►t Telephone#5 Telephone# [1 Type of Building _,,X Dwelling- No. of Bedrooms _ Other - Type of Building No. of persons Lot Size 11, d S 9L sq. ft. Garbage grinder ( } Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (mina required) iCz gpd Calculated design flow 3 30 Design flow provided Aj.,A!; gpd Plan: Date 7 1111 1-1 Number of sheets I Revision Date Title Description of Soil (s) _ Soil Evaluator Form No. Name of Soil Evaluator rri ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS - w9rsml— 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 Com fiance has been issued by the Board of Health. Signed o..� Date—ti Inspections co, / 8/1-7 / fn 5,o S, h 6 (x l t4 No.e2 t.) i - "i 7 fi f 7'fr'EE�4 COMMONWEALTH OFMASSAC14USET 57 Board pfHealth. y&:gt4o�T%1 , MA. " CERTIFICATE Of COMPLIANCE - Description of Work: ❑ Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed (A Repaired (t ), Upgraded Abandoned ( ) by: at 1 n hA,, n has been installed application No. Installer IN , ( , Designer: 1-t f The issuance of d with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated ZY ^ Approved Design Flow pd) that the system will function as designed. No.����1�4�..1�a�-_Oj!•1..9 iP)C COIF MONWEALT14 OF MASSACHUSETTS Board of Health, V"U O I M-4 MA. � DISPOSAL -SYSTEM CONSTRUCTION PERMIT M FEE - 51 Permission is hereby granted to; Construct( Repair( )' Upgrade(t/ Abandon( ) an individual sewage disposal system at 1'^ as described in the application for Disposal System Construction Permit No. J. � >� ated/.' Provided: Construction shall be completed within tjar- h date of this perm' . All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date ` Board of Health