HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE'
g 0V-D C-18-0 2-is 2 COMMONWIAITH OF MASSACHUSETTS d ° 3 q
°ai d of Health Y4,t-v" Q-+r-' �MA.
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(.) Repair( )Upgrade�W Abandon( ) �ompiete System individual Components
Location
Owner's Name
Map/Parcel#
Address 6 WI-i r i^
Lot#,
Telephone# Q-? - �o?�r `' 4 e
Installer's Name �� '1�Jw�w�
Designer's Name ; Q Q /�y ty wt C
Address C p /
�w t_
Address / ,/� / J
%Z CJ�a CJ ,MS.$ t 1 j '/,e +e k
Telephone#
Telephone# 6?-- -77-,7 c3 13 A OZ
Type of Building /�S t� jets fi^tn S Lt �q wt ai �� Lot Size l� �® sq. ft.
Dwelling - No. ,of Bedrooms S~ Garbage grinder ( )
Other - Type of Building J/ A No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures LVJ A
Design Flow (min. required) -55-1j gpd Calculated design flow Design flow provided 6/ :Z gpd
Plan: Date gJ 1.7 / 1 k Number of sheets 2 Revision Date
Title 1�.�2?�ci .t Gt� Jac �u cf-CtM ��� F o�c 1� Gi c i �s �� !' Q /' /► tCr at:41 �clY!—�
Description ofSoil (s)
40
Soil Evaluator Form No. Name of Soil Evaluator-[ k --� 1-C-2 Date of Evaluation
G / sE JSYZ
yi.h +C
DESCRIPTION OF REPAIRS OR ALTERATIONS MP.--j P-69 x 4 ►1d -(;AS
The undersigned agrees to ins�e��em
tn
sc dividual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further agrees to place op2jigon until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
InspectionsZY
Vllwiry L �
No..FEE co
UV
COMMONWEALTH OF MASSACHUQ'TTS
Board of Health, Y4 r (" 04 1AIN
.CERTIFICATE OF COMPLIANCE
Description of Work: `?Individual Component(s), ;nplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded), Abandoned(
by: t)
at I 2-c( 1 Ct rMCA,-i-(n
has been installed 'n accordance with the ,provisions of 310 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application No. _ dated.f_ Approved Design Flow !° a (d)
- e�J
.Installer /j,o 01 A
Designer: �� �'� i�cs��j Inspector: f Date:
Z 4)
The issuance of this permit shall not be construed as a guard a that the system will function as designed.
No. UC) � 0 FEE C�
COMMONWEALTH Of MASSACHUSETTS 3
Board of Healhl,
DISPOSAL. SYSTEM[ CONSTRUCTION' PERMIT
Permission isherebygranted to; Construct( .) Repair( ) UpgradeX Abandon( ) anindi-,idualsewagedisposal'system
at (It -lk eL r^ - as described in. the application for'
Disposal System Construction Permit No. ' dated/-( -%r r .
Provided: Construction shall be completed within the date of this pert it. All local co d'dons must be met..
!-,� Form 1255 Rev.S/95 A.M. Sulkin Co. Chadeslown, Mn Date/ 7 ' IrE Board of Health