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HomeMy WebLinkAboutApp-Permit-ComplianceNo. _ QTs�O UO 1 "'g -0V0 J 1 8 FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, Y U" MA. PLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Applci adonfo ermit to Construct( ) Repair( ) Upgrade( Abandon( - omplete System ❑ Individual Components Location iC2 Owner's Nameja Map/Parcel#9-02 Address �N S kkt Lot# Telephone# Installer's Name ° �,�t Designer's Name Address Address Telephone# '7[ . -(s;lj/p Telephone# 5710 p Type of Building �'�'S��.'y�� Lot Size Qo'" sq. ft. Dwelling - No. of Bedrooms Z! [c Garbage grinder ( ) Other Type of Building No. of persons Showers ( ), Cafeteria Other Fixtures ? Design Flow (min. required) 3.3o gpd Calculated design flow Design flow provided gpd Plan Date 71 V 7, AO Number of sheets ' Revision Date Title Description of Sbil(s) Jp� �c OSS /": dc"'-wes rlf�,Lis•°+ ��{'!/�% l��.�e.i Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees ton 3, place the system in operation until a Certificate of Co lianhas been issued by the Board of Health. Signed Date ©7 Id'7 Inspections --,v23 -rho. No."' ! '� `_FEESY 60 COMMONWEALT14 OF MASSAETTS dk Board of Health, V A°LSM O U°'E A , AM. �X Z 4S CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) omplete System M1 The under" ned hereby certify that the Seura e Disposal System; Constructed( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: �� Y✓ -pp ^01, at has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. & dated,Approved Design Flow (gpd) Installer Designer: S� ����'Inspector: Date: s The issuance of this permit shall not be construed as a guarant/ee that the system will function as designed. No. ✓ { �? C -17 X53� -- - FEE M S COMMONWEALTH LTH OF MASSACHUSETTS cht3(d � Board of Health, YA R-iM o 0-V)A , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repai Upgrade( ) Abandon( ) an individual sewage disposal system at filr e -rte P!,;; j 0 as described in the application for Disposal System Construction Permit No. / -- )-I�; dated Provided: Construction shall be completed withinjhxge&�f the date of this per m3�t.. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. ChMestavn, Date ' / Board of Health