HomeMy WebLinkAboutApp-Permit-ComplianceNo. C461 `{ �L®` n `'� W7� FEE
COMMONWEALTH OF MASSACHUSETTS
y Board of Health, )6W&0 Q1W MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrade(K) Abandon( ) - ekComplete System ❑ Individual Components
Location DEE-,P j3floovc
Owner's Name &J K9 ,14ZA 1,(O, -JAL
Map/Parcel# ! dF) 3 SZ
Address
Lot#
Telephone#
Installer's Name,,-4
Designer's Name PAw 4 j f7EA W/,j,,,,Vu
Address s f �C 411 1? VJ f C.p
Address'-JAl S' S L�'k
Telephone# SU z- SS 65
Telephone# So a er-37-,SS GS
Type of Building J�� L� C t. ��" 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 5 C) gpd Calculated design flow 336. 16 Design flow provided 31 G -6, gpd
Plan: Date 12-11 / l i
Title i I'l C: V
Description of Sbil(s) _
Soil Evaluator Form No.
SC -Z
Number of sheets I
Pv_SC�4D 2Ut_71 r,,-4_1
Revision Date
Name of Soil Evaluator 0 M,' 5 Uti Date of Evaluation I/ 13 0 % 1
DESCRIPTION OF REPAIRS OR ALTERATIONS J 500 D - ASO -k 't S a S C>l� (3i -? O S'
2 A'r j t_1 r ZW7o (Z -S,
The undersi ed agrees to ' o e described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further at
ees to t to pl sys n in operation until a Certificate of Com fiance has been issued by the Board of Health.
Signed \ e-> Date Z �!
Inspections
No. i �42eKIAFEE
$5500
C®MM®NI.T1I Of MASSACHUSETTS � P -2`3I li _
Board of Health, , MA. Otis
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) U- Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded {), Abandoned ( )
by; i .,�wcy*arc� .- 'Ci 7",�U C®' l.�i 1i�J f-,� -� 7�4 t"11' �R*..1 L (-NAk I le—VLA I U 1\-J
at �� 1�C� � iS r'? L�C)ti( iC
has; been installed ig accordance with the rovis ons of{Kl0 CMR 15.00 (Title 5) a d the ap roved design plans/as-built plans relating to
application No. �� dated o %O . Approved Design Flow (gpd)
Installer ° �3 "� , c;.: a�-'j-\ 6�¢�
Designer: i�` 1'� ►. `)er- V -MAN.) Inspector: Date:
The issuance of this permit shall not be construed as a guar that the system will function as designed.
No. t, °� —� �� )4J��. i} r".�ttlJ~1'y FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Flt Pt"1.8� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(`) Abandon( ) an individual sewage disposal system
at )(� (: }' ij - f i) K.. j i
as described in the application for
Disposal System Construction Permit No., d ted
_V- 7
Provided: Construction shall be completed within three-gt �Tthe date ofthis t. All local co itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health '
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