HomeMy WebLinkAboutApp-Permit-Compliance1�'� L UT`y f �S
No. D C-11-6 Yk3
C�OMMONWEALTH Of MASSACHUSETTS
Board of Health, 1®QTA MA.
FEE �63100
6 63
& z / PLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑ Complete Syste><n,,Q-1fidividual Components
Location
Al 4.1�/� Y� S. 9
Owner's Name tock�
"l LvG�
Map/Parcel#
L®o
Address
Lot#
Telephone# i 7 6S- —
0tl7
Installer's Name a��� �—
Designer's Name Lgi4
Address �
Address t3&Y— 1 % s
Telephone#
Telephone# Co 8-
_ 31p
Type of Building 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 gpd Calculated design flow Q Design flow provided gpd
Plait: Date / I Number of sheets (J Revision Date
Title
Description of Sbii(s) &:"d io
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ��' dGp,4,��P, j� :.
The undersigned agree dXnst the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n o plac a sys in ' er til a Certificate of Compliance has been issued by the Board of Health.
Signed /" Date
Inspections
No. Q c— 7-003
® �-- CO MON LTH OF MASSAC14USETTS
Board of Health,� (j LM4 , MA.
FEE 4§56. 00
ICI 3&., --2,
CERTIFICATE OF COMPLIANCE
Description of Work: individual Component(s) ❑ Complete System bb,(
s;
/eaV4
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,1 bandoned ( )
by:�`1ii� C'�t SES Cc-yi '
at r1 "1 N11 e ! i 6 3..l' V1, A SO . t .tct A A _ - ---
has been installed in accordance wA the provisions of 310 CMR 15.00 (Title 5) an the approved design plans/as-built plans relating to
application No. CB dated "" '^-7. Approved Design Flow (gpd)"
Installer 5r. I t ick t� ('01 `� A Co Y1C) ];>.---) 11 C . ,[:��i ,I ,, .��►..�(J�d' �A df Jl�:
Designer:
I—J LA l2ti`l . I t (� Inspector: ✓�'l �✓
Date:
The issuance of this permit shall not be construed as a guarazAee that the system will function as designed.
No. ( i ,.i i I inti S i
COMMONWEALTH OF MASSACHUSETTS
Board of Health, VVAem C1 -ma , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
rs_-1=
FEE 4 SIT 60
3GG
Permission is hereby granted to; Construct( ) Repair( ) Upgrade�Abandon( ) an individual sewage disposal system
at 4 .'-f I, S C�,n `a-, �lri ;--1 r iAas. described in the application for
Disposal System Construction Permit No. datjed(,�-t'd
Provided: Construction shall be completed within of the date of this ei-Init. All local c ditions must be met.
form 1255 Rev, 5/96 A.M. Sulkin Co. Chddesfown, MA Date '"� Board of Health
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