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HomeMy WebLinkAboutApp-Permit-ComplianceN�. ��< �n°S ra q 8o,-pc-{S--=Z9y I 01-f_-3 COMMONWEALT14 Of MASSACHUSETTS Board of Health,MA. �11?/ APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct( ) Repair( ) Upgradt�ej/Abandon ( ) - ❑ Complete System ZdMidual Components Location Owner's Name Map/Parcel# Address Ue. Lot# Telephone# Q� -ISO 3 �O a Installer's Name Rohe V "r , P0, ov fz co (Z, Designer's NameRAS's E, r),&3 Address 94 Address .o . & A `� (�� � � , ,�/+ Telephone# l� O . L) 53 O Telephone# 50'-2,(atj-- R (jLIS Type of Building Lot Size U i C? V75_ sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other -Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. re uired) 1 gpd Calculated design flow 41.10 Design flow provided gpd Plait: Date Y �O % ,z Number of sheets 3 Revision Date Title Description of Sbil (s) 0 Soil Evaluator Form No. DESCRIPTION OF REP RSO� sALTER,(�TIONS :f NS"S4 {'1 Q. {� 64. �y 1 �I� Cl L-rr A -5-6 r' 3 ©S© The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees tonot ce tem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date No. 1 Board of Health, Y m MA MA. CERTIFICATE Of COMPLIANCE � Description of Work:-ErIndividuat Component(s) ❑ Complete System The undersigned hereby certify thPN the Sewage Disposal System; Constructed ( ), Repaired ( )O pgr ad Abandoned( by: i-+ (-,) vv- c- GAJ at 16 RHIWE V16 has been installed* ac or nce withthe rovis�gns of 0 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to application No. dated Appro,,edDesign Flow (gpd) Installer Ck ! ? 6,b l�- _ 0l) e_ Designer: it'\ iC lift z�e El, C& I t � P� �'nspector: ( Date: The issuance of this permit shall not be construed as a guar a that the system will function as designed. No.: - c 18-2!11-41 e-,,,,) , 0 U(c. Qq, -- = -- FEE j - f COMMONWEALTH I.TH Off' MASSACHUSETTS Board (f Health, )A a k M=� MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( Repair( ) UpgradeW Abandon( ) an individual sewage disposal system at d � Disposal System Construction Permit No. , dated as described in the application for Provided: Construction shall be completed within three years of the date of this permi . l local conditions must be met. t_1 Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date �' %,'Board of Health IC4f J