HomeMy WebLinkAboutApp-Permit-ComplianceNo. c.
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CO ®N EALTH OF MASSACHUSETTS C SV (v°
Board of Health, �� V 1 1Q , MA.
APPLICATION F04R DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair) Upgrade( ) Abandon( ) 0 Complete System ❑ Individual Components.
Location J—qi Sgrncte l e l�o°ed I -t (r,c ,, 4-L
Owner's Name a G4 i (_oeS Q
Map/Parcel# ! c3 yl l 23
Address po Gc)K la l 3 i i hct feta n, /s'jA
Lot#
Telephone#
Installer's Name w e- Mklitis
Designer's Name
Address J-7 /j%iTh5idt OeA1tir
Address
Telephone# S-0 g .- % %(p .- 3 `Y %
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. sof Bedrooms Garbage grinder(
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow providedgpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Sem. (i -1C1 01 1" hl
The undersigned ees to inst ie above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr ton to pla tem ' eratio rtificate of Compliance has been issued by the Board of `Health.
Sighede. Date U
,
No. Uri 1.'C,.
FEE
COMMONWEALTH OF MASSACHUSETTS
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Board of Health, Yie&O U / )4 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Componerit(s) ❑ Complete System a ,
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (Vj Upgraded
by: ,TUR AAP(hns 'AccySEpck4-e AC --
at E, -Ci bp#-,{"dtj RQA —r Y-OfMvuA f MA
has been installed in accordance 'ith the revisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. —� dated` /r7 . Approved Design Flow (gpd)
Installer aoe -
Designer: ---" Inspector: �` Date: t'
The issuance of this permit shall not be construed as a, guar,.I/, that the system will function as designed.
FEE
j j 7 � COMMONWEALTH Of MASSACHUSETTS
Board of Health, - m0 ,E4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is'.herebygranted to; Construct( ) Repair (>0 Upgrade( ) Abandon( ) an individual; sewage disposal system
at 2-9 bf\e(tiiACiiC / as described in the application for
Disposal System Construction Permit No./ "3..'7 dated 7
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Provided: Construction shall be completed within tl ar, of the d re of this permijt. All local conditi s must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date i 1goard of Health