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HomeMy WebLinkAboutApp-Permit-ComplianceISN -"- a 0o.(Z.O� J 00c-1i-6IZS COMMONWEALTH OF MASSACHUSETTS I -1-20 -7 Board of Health, Y O -N , MA. t. % APPLICATION FOR. DISPOSAL SYSTEM CONST UCTI OIRMIT Application for Permit to Construct( ) Repair( ) Upgrade Abandon( - ❑ Complete System U461gividual Components Location (`r't�t'0 Owner's Name t` b �L�� Map/Parcel# IRAddress Lot# Telephone# Installer's Name U T --r V Designer's Name11�Amp i AddressAddress Telephone# _ ?�Q Telephone# d Type of Buildingyy -- Lot Size � sq. ft. Dwelling No. of Bedrooms V Garbage grinder ( } Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures ` / �� Design Flow (mina required)�y1 > gpd Calculated design flow Design flow provided gpd Plan: Date 2M A Number of sheets C�1- Revision Date Title Description ofSbil(s) rAI] P ®f ,/`1 " (—© AMj S'A-09e. , ' Soil Evaluator Form No. Name of Soil Evahiatorl�i�1T,�D !'IDh� Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 1J,5s<,1,-) o l) R nit, (-5) SOO, 110 The undersigned agrees to install the ab ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the sys n op ation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections NO. •r'V1� V 1 �I G �, r l/( COMMONWEALTH OF MASSACHUSETA "FEE �1 Board of Health, VP&MO !3`C`" , MA. CERTIFICATE Of COMPLIANCE Description of Work:w.�"Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded (..*!iandoned ( ) by: U (- CQ.A)C at ti has been installed in accordance with the provision, o/310 CMR 15.00 (Title 5) and thap oved design plans/as-built plans relating to application No. dated / Approved Design`yFl�ow GGf� (gpd) Installer 6 t 11J_ kl/ " &4x. _ 6 _ Designer: J -) iv,, -I -r. QidCV- tom'- (5.1 6, -1 12(!.)�c"Inspector: The issuance of this permit shall not be construed as a guara system will function as designed. No. --R!()^7 �'� "".1�'i ( el-;,. o4.Ia-.C5 . f COMMONWEALTH OF 1''' ASSAC1L4USETTS Board ofHealth,&MDQ MA -.-.DISPOSAL . ;.., DISPOSA SYSTEM STEM �PERMIT cw.� FEE -1Q0 Permission is hereby granted to; Construct( ) Repair( ) Upgrade()--A6andon( ) an individual sewage disposal system at Lo E PA C r as as described in the application for Disposal System Construction Permit No. dated- "r 7 Provided: Construction shall be completed within s of the date of this pe mCi A11 local co z 'oris must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date - l Board of Health .� ,Ai