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HomeMy WebLinkAboutApp-Permit-CompliancebUb J 0 - (7— -' 0©10 3 / tQ FEE `��' �� COMMONWEALTH LTH ®F MASSACI4USETTS �� -7 V86 �. ��4 6 d/- � Board of Health, Y a Mn J 1 IJ MA. 15�M Cid_ )APPLICATION FOP, DISPOSAL SYSTLM CONSTRUCTION PERMIT A plication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components .ocation q ' L4j.4,r '' art -gee_ Owner's Name �C%10 �l �%®NAJ i`NtAIA/ ap/Parcel# 1 /S Address AR/ QL 7ciae-rx) f K Zeom 1 T ot# Telephone# Installer's Name & L .-- I o'�-SoN Designer's Name.hf�y 6 0 al/� 1 e�/1 �i�✓L Address�O&f y ��L�� ��—� �6� Address9 �iJ.�l/ S 7�/• Off/�!j d> Telephone# �2 6".r -4Z2 0 AY 73 I Telephone# J •- Type of Building 5201; ,el_ Fam"1/,i Lot Size _ sq. ft. Dwelling - No. of Bedrooms ��l�/`ODM Garbage grinder Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (mince u7re) �[� gpd Calculated design flow Design flow provided gpd Plan Date Y✓�--�/ Number of sheets Revision Date Title / Ilk 57 cSc_�G P%4/,/ Description of Sbil (s) 0 ';io /0;:- 1-5 3q; L S I L- 39- A l�1�6 D ms/ Soil Evaluator Form No. S 7 Name of Soil Evaluator AW G"ONSq k4S Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned t instaIl the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and ` further agrees to o lace the system in operation until a Certificate o�%% is has been issued by the Board of Health. " Signed Date iZ Ahe No. -�-"`` _q311 FEE C®MM®�1 1LTH OF MAS8AF I SETT . / c rl . -� Board of Health, EAI ot1I �-4 , Af ' CERTIFICATE Of COMPLIANCE / p� Description of Work: ❑ Individual Component(s) ❑ Complete System r' The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ),';Upggkaded ( ),Abandoned ( )� by:`J i at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the ap oved design plans/as-built plans relating to application No.dated, Z ~% . Approved Design Flow(gPd) Installer C" C` Designer: ;fa Inspector: Date: [ �J The issuance of this permit shall not be construed as a guarantee that the system will function designed. No. CJOTc7Il }� - - 1./ , a C�.S Cj } �}f•,a �i) t � � 3 FEE ��0r /H,2COMMONWEALTH OF MASSACHUSETTS -7L/3 6 Board of Health,J ��'1 D o -n4, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( epair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at Clt4.,) r.=L'"/�!"�15 as described in the application for Disposal System Construction Permit No. - =,O.7 ' dated r f Provided: Construction shall be completed within . . � the date of this permit. Al ocal conditi s ust be met. Form 1255 Rev. 5/96 A.M. SuI„kiinn CO. Chaaddessttoow�, MA Date _ oard of Health