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HomeMy WebLinkAboutApp-Permit-ComplianceFEE -7 V v C®MM©N � �� CHU§E��� ,.�4 LTH D F'T. Board of Health, 1146 ROUTE 28 , MA. �e f APPLICATION FOR DISPO'WMM'MffflUCT1ON PERMIT � Application for a Permit to Construct( ) Repair( Upgradef,<AbandonO - ❑ Complete System „0 Individual Components Location 61 Owner's Name R1 60 A K k! L L- Map/Parcel# MAO sct ,4(CEL a Address 4-q- #"dHta&AjV TkA4L $'esµ, `JiAAO eGT 06 Lot# Telephone# Installer's Name FCED S Ric," Designer's Name 76 �LC� Address 2J1 4%tJf1 0" joq H 8/� g Address l��e�C 2 / 'Z /� GW a� Telephone# S6/f Telephone# a Type of Building p` j e�+`i -0s Lot Size /ti 'Z 1 i sq. ft. Dwelling - No. of Bedrooms IV, Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) 2 ZO Plan: Date *—S—M-C� Title gpd Calculated design flow O. Design flow provided 73 41gpd Number of sheets V Revision Date Description of Soil (s) 1_ 97 01A4-J Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS L� The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees tto, nt to !"system in operation until a Certificateof Compliance has been issued by the Board of Health. Signed rf�l'lfP Date !'Z act Inspections ) `/� "Q & 01 � v11 nk� cone, 6 /l�`�I.t (�A rd S-o 5 10 S(e. �1 Po v No. H�`Ti� FEE Board of Health, MA. CERTIFICATE OF COMPLIANCE ) 6W 6/1-11' Description of Work: _;.&Tadividual Component(s) ❑ Complete System The undersigned hereby certify/that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,(- Abandoned ( ) by: at r hG-na-D �T has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the app oved design plans/as-built plans relating to application No. g - datedApproved Design Flow (gPd) Installer Designer: /. ( lL [f/ 5 Inspector: Date: The issuance of this permit shall not be construed as a guarantee fl t the system will function as designed. A - - No. fJ / - F , S • K 1 C FEE 9?w a Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade (_,) Abandon( ) an individual sewage disposal system at I C-Lc (- ��c�2 t� S1- / as described in the application for Disposal System Construction Permit No. G� , dated 0'e� Provided: Construction shall be completed within� - l�the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date Board of Health c