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HomeMy WebLinkAboutApp-Permit-ComplianceNo. �L� y� FEE 4 � OD ,;rX-RCOMMONWEALTH OF MASSAC USETTS (;Qi2*4q267 Board of Health, j 0-r VY) o APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for Permit to Construct( ) RepairwUpgrade( ) Abandon( ) - ❑ Complete System 1d Individual Components Location '� lU C . j,(), rMo. Owner's Name %i q)l�Yh ,! �5, Map/Parcel#��� Address (JPJ•/?jy�� Lot# Sy Telephone#�/ Installer's Namer �vtc,uu. }YUGY��OY1 l Designer's Name Addressy� Address MCl N+ Telephone# x`03- e%& _ '° 5�1G, Telephone# �� - 3�,� _ zlyflf Type of Building Lot Size 14 16W40 ' sq. ft. Dwelling - No. of Bedrooms - Garbage grinder( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 3.30 gpd Calculated design flow Design flow provided 336 gpd Plan: Date Qola 'ozol 8 Number of sheets Revision Date Title /—' / M 1Ve1' L - e- L. Description of Sbil (s) Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Date of Evaluation The undersigned agrees to install the ab�mo described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to pl the sys eration until a Certificate of Complian ce has been issued by the Board of Health. Signed Date No. �(�ie�{�°�j� " FEE -C) COMMONWEALT14 OF MASSACHUSETTS Board of Health, ! t' f r)yt L 4-> , MA. C ERTIFICATE Of COMPLIANCE Description of Work: r Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired W, Upgraded ( ), Abandoned ( ) by: at has been installed i accor nce with the rovi$ sof CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated '� 1 Approved Design Flow:3 (gpd) Installer l csr rl -.:} i r,� -Y', �� ar, �_inC sI i'-) Designer; L)Cnack-rEr..,��P—finj Inspector: ff� ( i Date5 A" � The issuance of this permit shall not be construed as a guarantee that the system will function as designed. J No. s}T 9 1 'i �; — t'M?{Li LXFEE 7/ COMMONWEALTH OF MASSACHUSETTS Board of Health, �l �i o�' iz5l �_z ""�-f '1 , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repairs Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for ... ,. `' � Disposal System Construction Permit No. , dated #t Provided: Construction shall be completed within of the date of this permit m, jtl local lcc�onditions ttst be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date /' Board of Health