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HomeMy WebLinkAboutApp-Permit-Compliance�� �/ No. V O !J` 1, ���''" FEE _olly--10 r 0Wc4 COMMONWEALTH OF MASSAC14USETTS 383E �. P&J �� Board of Health, �f� , MA. % 7". T7��A4LICATIONCONSTRUCTION PERMIT a j Z Z plication for a Permit to Construct( Repair Upgrade( Abandon( - 0 Complete System ❑ Individual Components Location �Q �i4 %y9//✓ J'��/v�+F/'�� Owner's Name Map/Parcel# �i �%/�' �/Q,�� ���` Address Lot# 70 Telephone# Installer's 14ame,.4L-/ Designer's Name 4) P • q/ 0.('9 Address��Q�T ji�� AddressGl MAI( 5T *W#ViNPC' yv1�1. Telephone# 7- —(, Telephone# ��_ 36Z - �►� `i r Type of Building -DLO t/LO.�Lot Size sq. £t. Dwelling - No. of Bedrooms Garbage grinder { Other - Type of Building No. of persons Showers ( ), Cafeteria Other Fixtures Design Flow (min, reuir ) 1330 gpd Calculated design flow J � D Design flow provided � gpd Plan: Date MAIN Number of sheets 1. Revision Date Title V Me— Description of S�oil(s) 0. s b R Soil Evaluator Form No. %3 87� Name of Soil Evaluator C0,4 /� 1%Z/ Date of Evaluation �� DESCRIPTION OF REPAIRS OR ALTERATIONS NF-") 15-00 c -,4L 7-ertJ 0 -P IS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agre s c of to 1 e the system operation until a Certificate of ConApliance has been issued by the Board of Health. Signed Date p .Inspections. . Of No. ar i Ie� �, 117 ' � � � FEE 5` ; 0 0 Board of Health, MA. CERTIFICATE Of COMPLIANCE o �c2/!8 Description of Work:. ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired, Upgraded ( ), Aban oned ( ) by itt_.. 1od7+Mf .rvtrl 14•• at W, C'F+G+ <-,-AN)Le4� � 1j¢�2yi/t©1TC 1�t t iii G7Z�� has been installed ' 1 acc dance with the provrsr ns o 0 CMR 15.00 (Title 5) and the a4proved; design plans/as-built plans relating to application No. 7k— /'Ng dated �' c . Approved Design Flow! ! (gpd) cytG G�iJIJti`rtai ' }1_i'�! Installer C_-� L(Fe vXc>-_a4VKT166-j U -e- �oRi !4 , �1� C�y�j Designer: I.Ot.f1.1(. qrk e2S rlAiL-1 tLc�nsp The issuance of .this permit shall not be construed as a Date that the system will function as designed. COMMONWEALTU OF MASSACHUSETTS Board of Health, &i?w��)7)4 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT !� Ni FEE sJi:. t �0 �4 } 4 Permission is hereby granted to,° Construct( ) RepairX Upgrade ( ) Abandon( } an individual sewage disposal system at %`� '` ��7 � (" as described in the application for Disposal System Construction Permit No. r dated Provided: Construction shall be completed within three ears of the date of this permit. All local condidons.:�yust be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. C^h�haaftown, MA Date � � /B`oar/djtotf Health