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HomeMy WebLinkAboutApp-Permit-Compliance`No. Q q— sl�, FEE COMMONWEALTH OF MASSACHUSETTS YARNPICUTH HEALTH DEFT. Board of Health, , M,4.. APPLICATION FOP, DISPO%VMfftJCTION PERMIT Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location Owner's Name !� Map/Parcel# Address a Lot# Telephone# S -OV — a. S-43 ; 8Gj t Installer's Name ccs Designer's Name Address ., o G _ Address Telephone# ®� _ Telephone# Type of Building _�P r '�4,e ti`s % Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) Plan: Date Title Description of Snil(s) Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator Design flow provided Revision Date Date of Evaluation DESCCRRIPTION OF REPAIRSS OR ALTERATIONS 17e err, ,i one Via/ ddl�1 gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to noto place the system in operation until a Certificate of Compliance has been issued by the Board of Health. �e l" .� Date Signed 6,. .� roof sup�rv.`s Inspections Io FQ cda"v-% . HAY '-war 1. , -O'I<• No. 07 � COMMONWEALTH MMNWTH F MASSACHUSETTS 1 Board of Health, v^ w� , MA.(� c.. -T 7TA ��-4CERTIFICATE ©f COMPLIANCE r RTnG / Descnption oiork: �O Individual Component(s) C3 Complete System °� The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (L),,"'Upgraded ( ), Abandoned ( ) by: at% has been installed in accordance with the pro sions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated L /0 log . Approved Design Flow ---- (gpd) Installer r g � Designer: -� Inspector: ►� t� Date: G U The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. O cf=J FEE �.%• .�.o- Cr Board of Health, ✓ n'� o u ( , MA. C)^ DISPOSAL SYSTd4 CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( tj"" Upgrade( ) Abandon( ) an individual sewage disposal system at 2Ziel I-ISS5�" 7—)T—. as described in the application for Disposal System Construction Permit No. 69— _, dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date f O U � Board of Health