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Home My WebLink AboutApp-Permit-ComplianceNo. o -7-030-7 i3��M - 19 -0015-59 FEE �-.2 s7 COMMON LTH ®� MA!��HUSETTS YARMCOUT Board of Health, 1146 ROUTE 28 , MA. APPLICATION FOR DISP®TAMM' IT Application for a Permit to Construct( ) Repair( ) Upgrad Abandon() - Complete System ❑ Individual Components Location (55 06YVIOW :57- Owner's Name 7 tJ -t r=<o A Map/Parcel# �� g Address 15-S Fj of `� pp Lot# Telephone# Installer's NameBEGc�S-D� C I Designer's Name ,�, C &��IA2.Et- =N Address1 5 �'� PA -AA Address -U54 (2? -AW jqt0/ Telephone# s Telephone# 5042., _ -6 3"T Type of Building V G -5, L h C LJ T-14-(, Lot Size <I14,g sq. ft. Dwelling - No. of Bedrooms 1 Garbage grinder ( ) Other - Type of Building Other Fixtures No. of persons Showers ( ), Cafeteria ( ) Design Flow (min. required) 5:0 gpd Calculated design flow Design flow provided 5-57, S gpd Plan: Date C1 - 1;Z-" ;�oC I Number of sheets ( Revision Date Title t S S CSAY0 Ek) SZ0?�� WEA YA RLAIQ O 66 E-1 Description of Soil(s) 0-nA- s& S,�WZ) Com, OR" l Ski 1?LAtj Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS ORALTERATIONS XO S -44<X - k)t-N >' A, 500 �^'�4c c �� - �© 5 ( TCC wf Cu -j 14 - Z -r) A _ )2, t»( 'M (te) <e -5n (ZI-,m.c_L no 14 -ax) 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 to ce the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Lei - Inspections G1 No. Utl '^j� "' o q EE 15, boCOMMONWEALTH Of MASaCH S 7 7 Board of Health, I \/ MA. CERTIFIC E OF COMPLIANCE Description of Work: ❑ Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( ) by: (�G,LQto L klg-4, 41z (Z4TQ4 at 155 I(3 Y V11SLo 5r WEST Y,49AW07%-( has been installed in accordance with the p visions of 310 CMR 15.00 (Title 5) and the, awe 7/d design plans/as-built plans relating to application No. f' dated Dproved Design Flow S /, C/ (gpd) In C A P W L ,,,= E r P &I S el tc -}- Designer:_!A/C�iCldtT -+4.� InspectorAtee Date: The issuance of this permit shall not be construed as a guart the system will function as designed. 7- 2 4`7 COMMONWEALT Of MASSACHUSETTS Board of Health, yT kl oo-n-t , MA. DISPOSAL S SUM CONSTRUCTION PERMIT FEE 55'0() (" 0 (033 Permission is hereby granted to; Construct( ) Repair(/ ) Upgrade Abandon ( ) an individual sewage disposal system at 155 pow" S -'RST' W. ldA-kA4oUx* 7 as described in the application for Disposal System Construction Permit No. _ r , dated _ ms's Provided: Construction shall be completed within trrce years of the date of this permit. 7 l local cond''ons must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date q -)-4- 3oard of Health 1.