HomeMy WebLinkAboutApp-Permit-ComplianceNo. �0RDC— 1 /43 S6
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Boar d of Health, y ^m ool k , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application for a Permit to Construct( ) Repair( ). Upgrade' Abandon( - ❑ Complete System A Individual Components
LocationV ,1 --
Owner's Name i T'e vie �� �Z�.0 Cr 10,_5 i./
Map/Parcel# 51-9
Address _ %A�*n�l-�c.��J � 5. !4 ro,C4 A.
Lot# Loa- 3 �C_/� �3Sf 114
Telephone#
Installer's Name -
Designer's;. Name IEFA i A a.ee1
Address "'
1 o ��,�U
�/
Address Z �v G,SS`i-��-�c� P� S410 -F,
i
Telephone# s -
Telephone# �t43'- 47-7 -S p3 MA aZ(-q'i
Type of Building I Str i/1'l�t �� Lot Size sq. ft
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building /,j A No. of persons Showers ( ), Cafeteria (
Other Fixtures N16y
Design Flow (min, required) 1 y a gpd Calculated design flowy qd Design flow provided q q -7 gpd
Plan: Date.
SJ ?C -j j 1-7 Number of sheets 2- Revision Date
Title PtbIn rse cAe A q., 33 AyA-i--a-j<-tv cS i ! -5. is ✓� ` ii✓
Description of Soils) fl --�" 74 .S - --56 B.' LG g� �h✓4 C 1. -Ce dr r=; S ?, y �. A C'Q1 '_I S 1 ,.�
Soil Evaluator Form No. Name of Soil Evaluator�l n �'�4 c �r1�- Date of Evaluation (F
DESCRIPTION OF REPAIRS OR ALTERATIONS I ui '
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
SigneDate la-
Inspections
a Inspections
i FEE S
COMMONWEALT14 OF MASSACHUSETTS 1
Board of Health, t tea✓ rti c v # L" MA. B 1�0�'��
CERTIFICATE Of COMPLIANCE �
Description of Work: 'Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded (4.r-AI57andoned ( )'
by: -2006-rZA5
has been installed in accor ance with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No; � r= dated f�`t Approved Design Fl- ?7 (gpd)
Installer
Designer: BE -FL-v 1hAr e {ti i = = Inspector: - +] • &r°t&,j Date: Id /to
The issuance of this permit shall not be construed as a guarantee -that the system will function as designed.;;
No.i11 FEEy7-
7
COMMONWEALTH OF MASSACHUSETTS &"— 4
Board of Health,MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to Construct(. ) Repair( ) Upgrade-) Abandon ( ) an individual sewage disposal system
a
at ?3�-v„ �- -�t 5 �� as described in the application for
Disposal System Construction Permit No. 7 r :i , dated
Provided: Construction shall be completed within t4� of he d to of this peri AlI cal conditions nu4st be;met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chahstown, MA Date Id 'Y1 7Board of Health Z-'