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HomeMy WebLinkAboutApp-Permit-ComplianceNom" 17'63 Z &L-Di12-t8-00 l q,3 / '�` COMMONWEALTH OF MASSAC14USETTS s 7.4 Board of Health, Y 1laW 0114 , MA. z APPLICATION FOR DISPOSAL SYSTEM CONST UCTION PERMIT 0 , lication for a Permit to Construct( ) Repair( ) Upgrad AbandonO - Complete System 0 Individual Components th 1W/ Location cc, Owner's Name —C—Ytyons Map/Parcel# 7 a Address -- 0390 Lot# Telephone# Installer's NameI`A AS � ��d Designer's Name Dpii - CC4 Address 3 / tD© 1�1/t� f y Address Telephone# i-19,379 66 Telephone# 3 Type of Building Lot Size sq. ft; Dwelling - No. of Bedrooms t, Garbage grinder { Other - Type of Building No. of persons Showers O, Cafeteria Other Fixtures Design Flow (min,neuired) 41°40 gpd Calculated design flow 41fDesign flow provided' Plan: Date. 6811 47 Nutnberofsheets i Revision Date a�8/ Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation — DESCRIPTION OF REPAIRS OR ALTERATIONS gpd The undersigned agrees to' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr not to ac the system in operation until a Certificate of C mp 'ance has been issued by the Board of Health.. Signed. r Date ��% %� / 7 - Na. / ft #5G!Abe-!)-Ga2 t ,�FEE � _ - COMMONWEALTH OF MASSA-CHUSET S � p,�-r �7� � sly Board of Health, 7AJZM0 (STH , MA. � CERTIFICATE Of COMPLIANCE Description of Work: 0 Individual Component(s) '®'Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: CSV s rV �1i S �,�C�1 I%kT7 C)/LJ at has been installed in accordance with the rovis ctBs o f3J4CMR 15.00 (Title 5) and th ap ved design plans/as-built plans relating to application No. i 7- dated Approved Design Flow g Installer �_ Designer: J.' r., i f� �.�..� �y (.g•�r? �: �: ���"l � , Inspector:.. �' � ate: � The issuance of this permit shall not be construed as a, guarantee at the system will function as designed. No: l >f , ..; i;.:� -tl �i/iN C E-xci-A J FEE l COMMONWEALTH OF MASSACHUSETTS 7 Board of Health, V62NO Uni , MA• DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herebygranted to; Construct( ) Repair( ) Upgrade( <Abandon( ) an individual sewage disposal system at ' s% Chi 1 . `" A LC. / as described in. the application for Disposal System Construction Permit No. G; dated ! C Provided: Construction shall be completed within of the date of this pe rt. 1 local conditions must be met. Form 1255 Rev: 5/96 A.M.,Sulkin Co. ChMeslown, MA Date �� / Board of Health C'