HomeMy WebLinkAboutApp-Permit-ComplianceNo. � VG —4(1 6S FEE . d�
L /G --:�'US" COMMONWEALTH OF MASSAC14USETTS C 2781
Board of Health, TJgIfj , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRLJTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - Complete System ❑ Individual Components
Location .�
Owner's Name
-"-A o y, -e
Map/Parcel#
Address L/U'-1
C>Jcp f-,„ yl ('../C l -0-r
Lot#
Telephone#
Installer's Name �CSLc n ';� �l`
Designer's Name
Ce r I ;.Po- If- 1 er,'
Address 3 60 l(ke
Address �p 3 a ,c /3 re v s� ^' �•
Telephone# Spg 8 / s / 3
Telephone# Sd
`1 is
Type of Building A� S�iT�Hs�� l' Lot Size sq. ft.
Dwelling No. of Bedrooms y Garbage grinder ( }
Other - Type of Building rt 51 KP ✓1 No. of persons o�_ Showers ( )) , Cafeteria
Other Fixtures
Design Flow (mi .required) gpd Calculated design flow Design flow provided gpd
Plan: Date �� I Number of sheets Revision Date
Title
Description of Soil (s) h
Soil Evaluator Form No. Name of Soil Evaluator I✓ n c. f! n 46 Date of Evaluation /o
DESCRIPTION OF REPAIRS OR ALTERATIONS lTl�t I !(/ 1'l ��^ l�},
I.v t t-/ 6 5fo r-c S v r rt v r� ►'-� -
The undersigned agrees. to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre-not�t lace system erado a Certificate of omp 'ance has been issued by the Board of Health.
Signed,,",�' Date ��
No. C 1 Y7 "i 6 6 r %i FEE . 0 0
� � ® COMMONWEALTH 41LTH OF SSACI-IUSETT � / ,z78 �
Board of Health, Yflrfd...he1e)UTIA , MA.
CERTIFICATE Of COMPLIANCE
Description of Work; ❑ Individual Component(s) LJ-e0--M-P-1ete System / �l
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded), Abandoned ( )
by: 0 cic-E 1 M 5 i TjIE �i Ee 1 C, ( t-) C
at
has been installed ;n accordance with�the provisions of 3 CMR 15.00 (Title 5) andd�the �a� oved design plans/as-built plans relating to
application No/dated/ Approved Design Flowj�-(gpd)
Installer 11,i )A. �''t f-�TZ
Designer: C, C.41 tas I Ix- (* J& j t ) , Inspector: l� i _ Date: _
The issuance of this permit shall not be construed as a guar t that the system will function as designed.
Board of Health, VAeMQ0T1+ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
a
FEE -!�T5 . OIL)
Permission is hereby granted to; Construct( ) Repair( ) Upgrade) Abandon( ) an individual sewage disposal system
at ►) C11 t S a N _ as described in the application for
Disposal System Construction Permit No. 116 dated r
Provided: Construction shall be completed withinlb�c oe ate of this per 4 1 local covOitions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co. Chedeslown,MA Date- oard of Health