HomeMy WebLinkAboutApp-Permit-ComplianceNo. IS -Of S (p
FEE'
COMMONWEALTH OF MASSAC14USETTSP/drl17y ,5
%LIDI ) ti/ M c9� MA. �e A Jff Board of ��etclth, _
I
1A LP-AII N t"K IBIS U31AL Sr5lhlvl 1.UNSTjKUCT1kJN i JR 11
Application for Permit to Construct( ) RepaiLk) Upgrade( ) Abandon( - V Complete System O Individual Components
Location ��-1-F-,eL
Owner's Nam w1 h
Map/Parcel#
Address
Lot# 4KTelephone#
,6O _ 0- .
Installer's Name Cywl
Designer's Name Is6c
Address 14- is_
Address';49 AoL,,Vv-U rk r
Telephone# - -" 6 -
Telephone# GZ)_ -Gol)
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building
Other Fixtures
No. of persons
Lot Size sq.ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) n1 1 O gpd Calculated design flow 3 e� Design flow provided 341 gpd
Plan: Date .�(i1 `vt ��u e"(O / Number of sheets CO * -�L Revision Date s�
Title �'t�sT W� Sr� % 4O 616kly-e Ave to h1�1 �'%rXMa. � �tAsracLuse IS
Description of Sows)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 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.
Signed Date
��
No. �� � �� � � FEE
/ COMMONWEALTH LTH OF MASSACHUSETTS
�l i (Nk) ice- MA.
Board of Health,,
CERTIFICATE OF COMPLIANCE
Description of Work: Cl Individual Component(s) 5 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (%e), Upgraded O, Abandoned ( )
by. L,YN,r
at 40 tS ram' IC ,s-
has been installed ii as
application No.
with the provisions of 3),0 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
dated .� .Z J Approved Design Flow (gpd)
Installer - ?"
-
Designer: Inspector: �Ei L�r, !Tc`�, , t Date:-76
The issuance of this permit shall not he -construed as a guarantee that the system will function as designed.
No. ,,e r ' ',9 $ " I J �:=1� kj FEET
COMMONWEALTH Off'MASSACHUSETTS
Board of Healtli,
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repai`r(( ) Upgrade(k) Abandon( ) an individual;, sewage disposal system
at _' VC11 o �'l�r� Y i,J y`�� LL. �? as described in the application for
Disposal System Construction Permit No. V 45f ' dated
Provided: Construction shall be completed within thxe�s o� t e4ate of this ermit. All local cond''tions trust be met..
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ��. C�3B and of Health t/