HomeMy WebLinkAboutApp-Permit-ComplianceNo. L7 -�og9B(,M-U®Cp FEE S i 00
-�� COMMONWEALTH OF MASSACHUSETTS � I OZ5
Board of llealth, _ //J- , MA.
APPLICATION FOR DISPOSAL SAYSEM CONSTRUCT'10 P MIT
Application for a,Permit to Construct( Repair( Upgrade( baonO LJ - Complete System Individual Components
Location
Pt4 GA5&k1T Cove CCRCkE
Owner's Name
T TA e
Map/Parcel#
149
Address Pa mo
A( T%i' O-Aw am Rax
Lot#
(�
Telephone#
Installer's NameIiAPEIJI06 � - �1�
Designer's Name
AddressJ
itGkt�'7� �"�'
Addressa4S"(I.Y
�I a
Telephone#
g 77 - -7 71
Telephone#S-OK
- '1 _. -Z
Type of Building R C�S- i 7) 61k)T l A'L- Lot Size� 7: � l � � sq. ft.
Dwelling - No. of Bedrooms Garbage grinder {
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (ricin, required) 3:30 gpd Calculated design flow Design flow provided?5?�3 gpd
Plan: Date 5 -115 - clot IS Number of sheets r Revision Date
Title 1-1 H E&.-A)J T enov e �ll►i�� YttK�'C@U(pCt robe--'
Description of goil(S) L0 4&,(q SA -00 Q— J.0 6i / .scar i17C 41,-j
Soil Evaluator Form No. Name of. Soil` Evaluator 1-1 ahtik GX T -T-- Date of Evaluation : "9 - X0 `9
DESCRIPTION OF REPAIRS OR ALTERATIONS � � � ��l t�� l j ooQ CzwL -"5tEV-C t -- "C�l��,
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to n placea system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
w
No. OWxs�;- oo
COMMONWEALTH Of MASSACHUSETTS v4 WV(P,
Board of Health, _WeMOLn MA.
CERTIFICATE Of COMPLIANCE
-
Description of Work: Individual Component(s) ❑Complete System.
The undersigned hereby certify that 'tic Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded (.-• -Abandoned O'
by _ fa�L� �' / Q go Y,t(:bhARD 54000
has been installed in accorda ce with the provisi ns 10 CMR 15A0 (Title 5) and the appr ved design plans/as-built plans relating ti
application No. l - dated f, . Approved Design Flow gpd)
Installer 0-Agrujim kie 'A3. 40�-Fehi 4
Designer: ; C_ �4L�?i 3 dA»L'�_;04- Inspector: f Date: !f / dl
The issuance of this permit; shall not be construed as a -xaiftee that the system will function as designed.
No. � r_ � ^'1391 ' � ��P" Grp/ (D � FEE
1�' - COMMONWEALTH QF MASSACHUSETTS
Board of Health, ygt��' MA.
DISPOSAL. SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at Iq !;&AZ " 00V9 as described in. the application for
Disposal System Construction Permit No. dated./'`
Provided: Construction shall be completed within t= s o he date of this p it. All local cc�n, ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date ! ? ; i5'oard of Health