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HomeMy WebLinkAboutApp-Permit-ComplianceNo.P%6� /- 5%o FEE S• 7'/6 MM WTSI OF MASSAC14USETTS Z1, 3074 Board of Health, Y , MA. .11 C APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT Application for Permit to Construct( ) Repair( ) Upgrade(-rAbandon( ) - Q1 omplete System D Individual Components Location Owner's Names �®,.e C , Map/Parcel# Address Lot# Telephone# Installer's Name Designer's Name AddressQQ M ` Address N,,.�x g � + ` Telephone# _ Telephone# pea. © _ Type of Building Lot Size /G7,/ sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (mina required) 3 gpd Calculated design flow Design flow provided JT 3 gpd Plan: Date c C (� 1 c'7 Number of sheets _ Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator SJ . Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS C1TZr� ,,.,V 14 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 y mm operation until a Certificate of Compliance has been issued by the Board of Health. Signed - / ?`/sy Gam/ Date '4� rezz/ � Inspections No. Y ... 1 Aho 'Ag FEE $575. 00 *' COMMONWEALTH OF NIASSACHUSETT (t*30q Board of Health,VA 0(—, MA, j CERTIFICATE Of COMPLIANCE 7— 6,f_7 Description of Work: ❑ Individual Component(s) 6 omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (.Abandoned ( ) by: c� at r has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) Installer :z- -- P Designer: VL_ L- r- V .g?.A,5-�-„Nc' , Inspector: Date: %'62 The issuance of this permit shall not be construed as a guarant " oeo that the system will function as designed. No. Y` —1—� L � 1 �P 1 il`i 1 Z o o" Fe ,.... FEE — COMMONWEALTH Of MASSACHUSETTS Board of Health, �_ n1 nk MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade{ Abandon( ) an individual sewage disposal system at �� --> mQ��� i.-�.a�.c_ 0 CL? as described in the application for Disposal System Construction Permit Not ?— , dated Provided: Construction shall be completed within three years of the date of this permit local condit19X-1§ must be met. Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadeslown, MA Date ? ' /"Board of Health