HomeMy WebLinkAboutApp-Permit-ComplianceNo. / *f / av FEE
10 3Z 15r COMIMI®N ALT fit► � ��IIJS�TTS o`�
� , �,.., .1 HEALTH DEPT.
M Board of Health, 1146 ROUTE 28 , ml.
APPLICATION FOR DISPOSAT
V . M f fT$I®N PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( - Z Complete System ❑ Individual Components
Location
Owner's Name Mf G.
Map/Parcel# M (30
Address
Lot# ' 00A
Telephone# 4�3
Installer's Name Q T2�L
Designer's Name Okn%I 2A %AAjLZ,2
Address 35a r/1�� ^ SIV, W
Address P o e ad °j�1 h� W �t MN
Telephone# t'1'�°b� 'L3_
Telephone# 50<6-3kiZ-"Z 1V22
Type of Building�� .Q�. ✓vt,1.t Lot Size 11, 0 0 O sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building _ No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) f l7 gpd Calculated design flow o Design flow provided 33 � . % `\ gpd
Plan: Date 11,-1 10 Number of sheets Revision Date
Title 'Soni: i22D� `ACL
Description ofSoil (s) aG 4n ZU,2% i.,0ck0A,1 51,.. i ZCo 2e& fo 71 05 10"o—, 114AIJ 2LI b3 �, /9•Zo Aj,,( 660,a5e. SlwA
Soil Evaluator Form No. Name of Soil Evaluator Dmkken M qo4- Date of Evaluation L-11,110
DESCRIPTION OF REPAIRS OR ALTERATIONS 1 Nb'�u-1 l l 1 l 5 D 0 � 4 ( (o n s �'' u� �'� Qn �, vr� ) A�Sfa t (1A 1660 qr1
c a� � i,� &VA A,'y 47 t�S11nn LI P,/," 14,�ti C,\u�" t �7Z II r�Qovu6 o
CY--� 110 0 Ll Al o s 4. r►. lk
The undersigned agrees install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not o lace the system in operation" until a Certificate of Compliance has been issued by the Board of Health.
Signed Date i••\ ),Z,31)%
as -1 6- 13�t
No.D �` �. r FEE
COMMONWEALTH OF MIASSAETT("
Board of Health, �� ✓� °�" , MA.
CERTIFICATE Of COMPLIANCE -
Description of Work: ❑ Individual Component(s) prComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed.,( )f, Repaired (+.Upgraded ( ), Abandoned ( )
at 1 �'t tr t� a+c,
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated ✓� �� %d . Approved Design Flow ( d/�
Installer ss -� r
Designer: D( -,O b, 01--, -A— Inspector: Date: �X �
The issuance of this permit shall not be construed as a guarantee Wat the system will function as designed.
No. / (/ i 7 FEE S S`
COMMONWEALTH LTH ®f MASSACHUSETTS Ike C W- '•
Board of Health, -,MA. a X89
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(/ Upgrade( ) Abandon( ) an individual sewage disposal system
at okms,�n� -A 0 C as described in the application for
Disposal System Construction Permit No. /j'�-� 7 , 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. Chaleslown, MA Date^/noard of Health