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HomeMy WebLinkAboutApp-Permit-ComplianceNo. go �Jc-{ -83512 COMMONWEALTH LTH ®F MASSAC14USETTS 5a Board of Health, Y d FEE '9 00 &A-008%,28 APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrad Bandon( ) - omplete System ❑ Individual Components Location Type: d 1' N' A) Q f— Owner's NamecArL o c Map/Parcel# a r Address f-AIIA C . CAX Lot# i a 3 8 Y O j Telephone# 5 Installer's Namey,'N Designer's Nameen's-3 �� . • �)IJ AddressAddress P, Q SJ1J Telephone#1:57- (; 5' ® Telephone#56,K -:-r+ Type of Building Lot Size r, 00 _ sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafgeja ( ) Other Fixtures i 7" U �! . Design Flow (min. required) -� gpd Calculated design flow Plan: Date 9 C �r � 1 ? Number of sheets `"( v -a Title Description of Soil(s) 0 Soil Evaluator Form No. /d J Name of Soil Design flow provided Revision Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS�� S:6 1 % C>r,) 4' Q �- • J 10 i`) K gpd 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 pl tem io4eration until a Certificate of Com liance has en issued by the Board of Health. ~ Signed Date ()Z2S Inspections AO COMMONWEALTH Of MASSACHUSETTS � FEE SCJ .�6 'l Board of Health, AeMc) UTH , MA. CERTIEIC -E ©F COMP..IA Cr - Description of Work: ❑ Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded), Abandoned ( ) by: R o6e r CR . G U 2 Co. XiJ C - at Dr, has been installed in accordantjwith the -d ,provisions ofY0 MR 15.00 (Title 5) a application No. '� ' .!i dated l % Approved Design Flow Installer (, 1':, k t~ �' JL 11 •oved design ;pllanns(/ass--built plans relating to Designer: i'l 5 i r i 4`e -w- Inspector: ' Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. ycu_^t ccztc_Cvt ..ravc,cc;.nno"goouoc,coc iuVr,1,00,oc?ri=�t.uo �;c .r,e: No. i�,00 1X- -' � ,ou (L- c U . FEE �`" Y5"-, ( %' -.�-- COMMONWEALTH Of MASSACHUSETTS d&9 00933 Board of Health, y�M'l0 UTA-¢ , MA. DISPOSAL SYSTEM ST CONSTRUCTION PERMIT Permission is herebygranted to; Construct( ) Repair( ) UpgradeV Abandon( ) an individual sewage disposal system at Disposal System Construction Permit No., dated %D rG� as described in the application for Provided: Construction shall be completedwithinthree years of the date of this per i t X6,11 lo11calalc�onditio must be met. Board of Health Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date t✓G�'/',f�