HomeMy WebLinkAboutApp-Permit-ComplianceNo. FE `00�
COMMONWEALTH Of MASSACHUSETTS
Board of Health, % kff* , MA. `� ,, ,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUd � PER-N�IT
Application for a Permit to Construct( ) Repair( ) UpgradW, `Abandon( ) - ❑ Complete System Individual Components
Location 24
Vot-.nn-E4/t-/ 2 o-1- D
Owner's Name
Map/Parcel#
(j ) 4-7
Address ZG
p tx-) Y,4%4/t� ,2)' .
Lot#
Telephone#
Installer's Name 599-'j„4-lCAP�V OCCAl/^1VV
Designer's Name
PJV A
Address
S �)� � 1 A�� 1C/iJ
Address 11�'
-SV&'K LJ411 WI&J i C1
Telephone#
(�
Telephone#
�2C f 3 Z
Type of Building IL f rt)
Dwelling - No. of Bedrooms 3
Other -Type of Building
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) 33-0 gpd Calculated design flow 33 Lf- Design flow provided 3 34 , gpd
Plait: Date i 1=j 1 ( Number of sheets 1 Revision Date
Title ,;I IE Pw V PLA ))AAS �p t/'w /? — �71 U.,Q
Description of Sbil (s) `�7 d^/E S'-A�
Soil Evaluator Form No. Name of Soil Evaluator 0 • /".5UN Date of Evaluation /112/1114
DESCRIPTION OF REPAIRS OR ALTERATIONS D^ 8,c, 7, ",S C 0 C61,, -,-51 -V b f W 3 ri: o
A/ r L7(LIN--T 0 2 vAv i
The and 'gne ees to inst a ove escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es to n to plat s to ' operation until a Certificate of Co plian has been issued by the Board of health.
Signed Date
~ Inspections
COMMONWEALTH OF MASSAC14USE+.,'
Board of Health, ) Q (r;'�� , MA.
CERTIFICATE Of COMPLIANCE
Descriptiotn of Work:..ail-dividual Component(s) ❑ Complete System
The undersigned/hereby certify thaf the Sewage Disposal System; Constructed `X�° Repaired ( ), Upgraded o)1bandoned ( }
has been installedin accordance with the provisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. _�, dated i) a Approved Design Flow ,(gpd)
Installer i� ,r - ' s
-.
i ®T=.4- %
Designer: �li l - a!� 4 4�' Inspector: Date:
The issuance of this permit shall not be construed as a guarant that the system will function as designed.
No. aI Ix - t, �; t i .' d" `s �� �� �.:.l �j g F FEE � '6. a
COMMONWEALTH LTR ®F MASS C14USETTS
Board of Health, (ayy a}- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repairx� Upgrade( ) Abandon( ) an individual sewage disposal system
at /,Gf��(�`���s� &�_ as described in the application for
Disposal System Construction Permit NV - dated '1 ``
Provided: Construction shall be completed.within�s o the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co, Chadeslown, MA Date /I)- -,��/Board.of Health