HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1 g7— 0 `3 4�i .���_
FEE
COMMONWEALTH OF MASSACHUSETTS �}-10�3�— � 6D
Board of health, )f4]2ffi0 QT)4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade Abandono
( mplete System O Individual Components
Location
Owner's Name &dd
Map/Parcel#Addressgq
Lot#
Telephone# rj9 -23
Installer's Name K
Designer's Name
-
Address 36 R
_ ekjft Address 1 r 'PQ ) a
Telephone#-
Telephone#SM - 36
Type of Building _ kes CQ e(1`"A Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder {
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min, required) -3--36 71
gpd Calculated design flow Design flow provided gpd
Plan: Date /O .11(m ./ o Number of sheets -3 Revision Date
Title
Description of Soil (s) d
Soil Evaluator Form No. % '17 r% Name of Soil Evaluator 601t) Gdb S'e 1 Vef%ate of Evaluation
c/ 1
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 p sys in o ration until a Certificate of Compliance has been issued by the Board of Health.
Signed • Date4 jqb,7
`fr to
No. U� ;'"f. / — f� f LAG' , f gE
COMMONWEALTH Off' MASSACHUSETTS �� y.�
Board of Health, �%� p ( , MA. r L �-7q
CERTIFICATE OF COMPLIANCE
Description of Work: Q Individual Component(s) Womplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded Abandoned ( )'
by pI't{� 00t&ratfVKS -tt)c:
at �t ! hnfoin 0�con r, 4 o 'Li - '; _", '
V
has been installed in acc rdan with the}�rovisi • s of1. CMR 15.00 (Title 5) and e owed design plans/as-built plans relating to
application No: f 7; dated' b / 7Approved Design Flow (gpd)
Installer p N. ) .-J
Designer: i�{rSJI i'a��AQ Inspector: / t Date: P-7
The issuance of this permit; shall 5 be construed as a guara•Y%e that the system will function as designed.
��1,114....' % .. ( I ' i"`l FEE C
No. .
COMMONWEALTH OF MASSACHUSETTS �-� (c��t 4 4-506-16 _56
Board of Health, V , MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct,( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
A 11
at W 1)11—PAron t as described in. the application for
1
Disposal System Construction Permit No. / % 'dated
Provided: Construction shall be completed within three years of the date of this perm ' . 1 local n ns must be met.
F
Form 1255/Rev. �5/ 6 A.M. Ykin Co. Chadeslown, atel 0 r�� ��Board of Health t f