HomeMy WebLinkAboutDOC002No. FEE
COMMONWEALTH OF MASSACHUSETTS
�SBoard of health, "(4 rM 0-,) I -L-A MA.
LICA 'ION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Applica 'Complete System Q Individual Components
t nor a Permit to Construct(.) Repair(.) Upgrade.K Abandon(
IiA
Location )-to 1
I
Owner's Name -qUj Irus
Map/Parcel#res
-7
(0
Adds
C%+-401$ r,
. ........
Lot#
Telephonelf
Installer's Name Pi /3uoncl
LAdtd
Designer's Name
r 3 61
Address 1 Z Vj , C,,.,j,-,
I
Telephone#
Telephone#.5-dIw:]��—U . .......... 0AJ4- 0 Zf.- 10
/2-e '\
Type of Building St d-CIrl h - Lot .size eS-700 sq. ft.
Dwelling - No. of Bedrooms r? Garbage grinder
Other - Type of Building -j I No. of persons Showers Cafeteria
---
Other Fixtures ri
Design Flow (min. required)
ired) gpd Calculated design flow
Plan: Date Z 1-7 Number of sheets
Title )n'bia-cl S -W
Description of Soil(s)
Soil Evaluator Form No.
-
Design flow provided 1'7 7 G gpd
Revision Date
'a Q
Name of Soil Evaluator e
f
1513fngA-Date of Evaluation 12-1 toJ:�t
v
DESCRIPTION OF REPAIRS OR ALTERATIONS -a Cf / S,-? X- !; I / e—
The undersigned agrees to install the e described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place
thesyst er on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 7
Inspections J,
Description of Work:
The undersiLmed her
by: VJ ' E 5 1.&
at, Ll 10
has been installed
application No: I
Installer
COMMONWEALT14 OF MASSACHUSETTS
Dec
AIA �,000 pew"',
Board of Henula, of 1 -7)
CERTIFICATE OF COMPLIANCE
El Individual Component(s) 9<Complete System
ay cer that the Sewage Disposal System;. Constructed Repaired Upgraded (X),
. i I
with the -ovisions o 31.0 CMR 15.00 (Title 5) and the ixpproved design plans/as-built plans relating to
dated Approved Design Flow�3- ria
(gpd)
Designer: =may c Ittl (A] r Al hAs Inspector:Ql-�j X60�%�
Date: -Zd
The issuance of this permit shall not be construed as a gudZee thaVthe system will function as designed.
No. FEESl�-).
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YAr,,yj o-, j MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to.; Construct( ) Repair( ) Upgrade,>-) Abandon( )anindividual sewage disposal system
at
as described in the application for
I I I � f
Disposal System Construction Permit No.. dated lei�'
p
'14 0 r must be met.
Provided: Construction shall be completed within Qa-fe�years 0 KSedate of this per i#. All local c nditSi
4 0 bns,m
ve
Form 1255 Re, 5/96 A.M. Sulkin Co. Chd-kitoard of Health ostown, MA Date
Z
,-7