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HomeMy WebLinkAboutApp-Permit-ComplianceNo. Ti! w 7C/%t" I 6-700 J FEE'( ✓ `� Ilk � t /l' a/� 6} �� Board of Iealth, )L4-RdQ1 , 1VIVC11ON LIGATION FORDISPOSAL. SYSTEM CONSTR. ��� IT plication fora Permit to Construct( ) Repa r(e4grade( ) Abandon( Complete System © Individual Components. ti;<a „ta Location Owner's Name a JF ` Map/Parcel# / 3 q Address 140 .- ` Lot# Telephone# Installer's Name Designer's Name J� 4 Address 1 fSAddress r �_ 4 Telephone# Telephone# Type of Building - Lot Size A0.2 sq. ft. Dwelling - No. of Bedrooms 2 Garbage grinder (�(j Other Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min, required) _�� b gpd Calculated design flow Design flow provided gpd Plan: Date S f 1 'l Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS ?.SZAAt�UL1 eY-kM-crIL Fob On -_C The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisionsofTITLE 5 and Further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.. r, Signed Date 1 t 1 Inspections No.& 60V --I b —32-S i � � F E <51tDO COMMONWEALT14 Or MASACHUSETT,4S AN, I ". 3 YA12PA0 �r + MA. Board of Health, , CERTIFICATE Or COMPLIANCE Description of Work: 0 Individual Component(s) Erl Complete System 177 I� The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded , Abandoned( ) by: M 7 at K has been installed i i acc rdance with the rovisions 10 CMR 15.00 (Title 5) and the roved design plans/as-built plans relating to application No. —, dated -r /�- . Approved Design Flow (gpd)' Installer `=' C-esr-(,,.r-Vk Designer:,;�t_%Inspector: Date:'r'r�` The issuance of this permit shall not be construed as a,gu tee that the system will function as designed. No. FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, ~OUTR- , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade 6t� Abandon( ) an individual sewage disposal system at t` t c C_u aP U0 r ` c CtAo A f as described in. the application for Disposal System Construction Permit No. D� dated Provided: Construction shall be completed within three years of the date of this per i All local conditiorismust be met. F,or�m ] 255 Re, 5/96 A.M. Sulkin Co: CAeslown, MA Date' /�k Board of Health //v 7; e�-'1 ...` ,��y