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HomeMy WebLinkAboutApp-Permit-ComplianceNo. BD "�Od�� " "�`� (1 EEEi 1757✓00 OMMON EALTH OF MASSACHUSETTS �� a /'��� Board of H`pealth, &- 0104 , MA I � " k,�C46PLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT ///G---)-/`7 Application fora Permit to Construct( ) Repair( ) Upgrade (cAbandon( ) - QIQKmplete System 0 Individual Components Locationll f _. Owner's Name i Map/Parcel# �/!/� %1-G.a.�lk eel 31 Address 9 CcLp4. Dat? ie --L S , al"% -06I Lot# Telephone# Installer's Name ` n Designer's Name:bwn o /4' AA�S! Address 1 1 �- r� /. L Address q "/) 5 T Telephone# 609 - Telephone# Type of Building e s .l rl, Ac—e, Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers O, Cafeteria ( ). Other Fixtures Design Flow (min. required) 20 gpd. Calculated design flow Design flow provided. gPd Plan: Date Number of sheets Revision Date Title Description of Soil (s) Soil Evaluatoi"Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS �� Gi�I 5 I 2-o &ba- (2 N ID SW ����- • � h �rn bel �- The underp a agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of MIX 5 and further a eesZoto top e t eration until a Certificate of Com Signed Dliance has been issued by the Board of Health. ate Inspections FEE ,a ,i, 06 No. l COMMONWEALTH Of MASSACHUSET C, 6 5 Board of Health, Yo , MA CERTIFICATE OF COMP-LIANCE Description of Work: ❑ Individual Component(s) bComplete System ` Theers nedIhereby certify that the Sewage Disposal System; Constructed O, Repaired ( ),Upgraded Aba►Ydoned ( ) C3( ri lG� has been installed' acc rs;e with the rovisi ns of CMR 15.00 (Title 5) and the, oved design plans/as-built plans relating to application -No. _.. dated / ._ Approved Design Flow (pd) —7 Installer t o f zi t `4) t W ��� J? �,�.{ �1 L -1 � ' `� Inspector: Date: Designer: �- i�--e p � � �. .. The issuance of this permit shall not be construed as a ggara that the system will function as designed. No. __.�,,? FEE s' CIC - , COMMONW LTI OF MASSACHUSETTS 7�ro'-d 8 Board of Health, Y4gmogh MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT PermissioAis hereby granted to Consmxuct( ) Repair( ) Upgrade (� Abandon( ) an individual, sewage disposal system at t t}` �� as described in the application for Disposal System Construction Permit No. /-7- dated �%. Provided: Construction shall be completed within ears of the date of this permit. All local conditions lust be met. J`f7 / }, Form 1255 jiev.5/95 A . Sulkin Co. Chadeslown, MA D/ate it ` B and of Health