HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6o 41c-0-1637 �e416 7 FEE'
COMMONWEALTH Of MASSACHUSETTS
' %� / t✓'� Boaidof Flealth, �( 1 , MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade44 Abandon( t -Complete System ❑ Individual Components
Location -�- L,At e/A-y-,i':VC
Owner's Name F%Z y wcI g 'aI1/G
Map/Parcel# Z)
Address
Lot#
Telephone#
Installer's Nam e
Designer's NameN�i� L/l/Ut iL(/%t hfF�
Address
Address/gg YNA/W S -F
Telephone#
Telephone#
Type of Building 1�1Si (� �/t t Va L _ Lot Size 1616 90 sq. ft
Dwelling - No. of Bedrooms 7 Garbage grinder ( )%'ll d
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
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Design Flow (min. required) n gpd Calculated design flow—,�— Design flow provided gpd
Plan: Date A" y ~ / f] Number of sheets Revision Date
Title
Description ofSoil (s) QLSol(– 10L%
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
P
ds 170
S-�-
The undersigned agre s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5.and
further ee t not t lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date/ 7
Inspections
No. X;( �;. "!`i_ C3-7 FEE 55, t
COMMON EALT14 OF MASSACHUSETTS � ���f�-7
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Board of Health, l--ZIM 6 �-i , MA. 17)
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CERTIFICATE OF COMP .LIANCP
Description of Work: 0 Individual Component(s) Oeomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired J/), Upgraded ( ), Abandoned O'
at
has been installed incordance with the rovisi ns o 1.0 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application No.--&�!,dated 6 Approved Design Flow (gpd)
Installer 2 A")r PE F. ►l{ QF- I �
Designer: •y " Ett, elA,,y,4d Inspector:
f– IF
l -�$ia� Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. li' �� ` ,-1> �'r L FEE
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COMMONWEALTH Of MASSACHUSETTS Ck4 q (f j
Board of Health, �h'' Qt,� —, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade (k)y Abandon ( ) an individual, sewage disposal system
at LyA, q. 4l'ij A� I� 111 %Du fI U/�G� ! as described in the application for
Disposal System Construction Permit No ~ ` _, dated A �U
Provided: Construction shall be completed within tur44wlke date of this perin
l local conditions must be met.
Form 1255 Rev. 5/96 A.M.Sulkin o.Chadeslown,MA Date 1 _ t r/ Board of:Health