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HomeMy WebLinkAboutApp-Permit-Compliancea ` No. /�/ /�1f FEE' COMMONWEALTH OF MASSACHUSETTS � Z� Board of llealth, _Td'(. , MA. APPLICATION FOP, DISPOSAL. SYSTEM CONSTRUCTION PERMIT. Application for a Permit to Construct( ) Repair( /Upgrade( ) Abandon( ) ❑ Complete System O Individual Components Location ,63 a rC4 ,fid C/1 C .—Dr Owner's Name f M Map/Parcel# JZ I Y,7 Address 636�nndurir,,% U Lot# Telephone# J ` —GZZ, Installer's Name 0 kA , fv cc� Designer's Name pp1 Address e TJCh�- Gr�P i91 Gri /� Q /lddress Telephone# Q 0 3 ej0 c7L6 Telephone* i� Type of Building :::�J 4,E)i C 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) gpd Calculated design flow Design flow providedgpd Plan: Date Number of sheets Revision Date Title Description ofSoil (s) Soil Evaluator Form No. Name. of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS dU ,rcr,vk /`JaVSC. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further aareesAo n t t iace the system m* o eration until a Certificate of Compliance has been issued by the Board of Health. Signed Dateo'f No.pZ) t� 6J : FEE CiU C®MMON�L.T14 OF MASSACHUSIETTO . � � � -7c Board of Health, _ �/Jli , MA. f/ CERTIFICATE Of COMPLIANCE fi Description of Work: Ci7Xndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( .)paired ( ); Upgraded ( T Abandoned ( } by: -= n/ ( Up-( 'r- l r ft w at (`7L'C4jiz(raj ..ted has been installed in accordance with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. ll %`?-r•% dated �, . Ap roved Design Flow - (gpd) Installer C'Ie) rluc,,A L.Li 6:y-, w �( J Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee thai the system will function,as>designed. FEE _ Od COMMONWEALTH Of MASSACHUSETTS Board of Health, OIA-0-A /A rTi'la- , MA. DISPOSAL SYSTEM CONSTRUCTI®NT PERMIT i Permission is hereby ted to Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual, sewage disposal system at � `'� r cc rte-zl-e kf 1�� � as described in the application for i Disposal System Construction Permit No. / — " 7 , dated f ! . Provided: Construction shall be completed within 4Zree � -. e date of this permit. All local conditions rnust be met. Form 1265 Rev. 5/96 A,M.,Suul,Co.Chaadestown,MA Date? I / Board of Health % i�