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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 0A+DC-4-7-0Z3-6 1 �i ull��l iii h ! 11 EVE� � A I1 �' ! 2 F �� i(,.41*_ ard of Health, lL�i�►�1011�i- Y, MA.A��P ,,jPL�Ib��__11 ATI®N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components Location l r S T, Owner's Name PR -r , i c) 41 K A L I Map/Parcel# LIC7 Address Jl-] Cewrer Ss-. A4Z1A00-j4P0CG Lot# (0 Telephone# _ 3 1051 Installer's NameRC�p,V--r 13.0()V Co Designer's Name R@ tj G AddressP a A0. Address P,�y &4 aS 9 AA00 ON Telephone# 03 - 5 Telephone# 1> r Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures No. of persons Lot Size <i sq. ft. Garbage grinder( ) —Showers( ), Cafeteria ( ) Design Flow (min. re110l © gpd Calculated design flow U �0 Design flow provided gpd Plan: Date l b,:)L Number of sheets l Revision Date Title Description of Soil(s) i Soil Evaluator Form No Name of Soil Evaluator _Date of Evaluation% �, � 1 � L 0 /QnnyvOa nDN DESCRIPTION OF REPAIRS OR ALTERATIONS « ' f G u' 1. M 'I /&) e_W c 6Aa r S IA N& STa pe 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 topla a cyst * operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date ni� l l Inspections 7— o, f k /`+Pi��(�'�" T �- �.---No. J3 otk Dc ®�[�'I®N I.TII Of �9[ SS SIUSE 7 2 S % a K� �/� Board of Health, Y gmotsn+ , MA. m7I/""1 1% CERTIFICATE OF COMPLIANCE Description of Work:.+'�1 Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: Qfu"e.ri 8.02a CO ,T, -J C at a 114 C e _0 I --e- C- ST. TZ has been installed in accordance with the provisions o 10 CMR 15.00 (Title 5) a t e approved design plans/as-built plans relating to application No. �-' "dated l j- / .Approved Design Flow Y (gpd) Installer { { 5 T1 Q 4iO) .. 002— Designer: 02. -Designer: i2-bN CF D i l LAr C,. Inspector: Date: The issuance of this permit shall not be construed as a tee that the system will function as designed. No. 60t+ `)C {%`Q 2 � (Z. ClLi(; FEE 5�;. 06 �- COMMONWEALTH OF MASSACHUSETTS Board of Health, Y OUT -A , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT C** Uoe"3! Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at o) l `4 C e -,o T - r S�' as described in the application for Disposal System Construction Permit No. 1 l, dated " - / ? . Provided: Construction shall be completed within f0� of the date of thisermit. All Ioc ndidons must be met. r " Form 1255 Rev. 5/96 A.M. Sulkin Co. Chad stawn, MA Data BO rd f Health A d 7411 �d? �:-� Wr'D��l9lri Sp / w 3