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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 30 WDC-Q l D 1'7 2— ��--/ C (IF-4ii, rca FEE' ©� 9MI MONW LTH OF MASSACHUSETTS Board of Health, �WQT4 I MA. FOR D ISPOS SYSTEM CONSTRUCTION PERMIT t�ef�UfpgradeO Abandon O - �omplete System O Individual Components Location Owner's Name Ai Map/Parcel# Address Lot# Telephone# -So'bi '^` zX0 - 96 Installer's Name i tf �^ Designer's Name Address U Address D OY l a� l/1C1:�o.S Telephone# t . j1(� - i Telephone#rob IJ- 90Y& Type of Building S ecle, . v �J Lot Size sq. ft. Dwelling -No. of Bedrooms Inc Garbage grinder( Other - Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures �ry Design Flow (min. required) 76 gpd Calculated des, n flow V Design flow provided � gpd Plan: Date 5" ! 1 017 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 59�j I /�� Jam"'"` � � ' ��f Gti'tel � 64' 9�ui'� The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Coniplian a has been issued by the Board of `Health. Signed Date Inspections 1::UV ` c% Cc A-r- a-cJ �PwAr-t,— czc yr No. is —' COMMONWEALTH OF MASSACHUSETTS 5 3 (,, Board of Health, yn&t Dy t \ , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) Neomplete System The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaire�pgraded ( ), Abandoned by: k�,4 r f .1 2- 11 at /,,yam. &/I t has been installed 'iz ac or�lance application No. l / , Installer f 77Xjsl; Designer: 4--*l�iG 1r►,.� Inspector: The issuance of^ this permit shall not be construed as a guaree that the system will function as designed. - — No. i �t t� "+ ��� . �f a A FEE 5, 00 COMMONWEALTH Of MASSACH JSETTS c,k3 536 r Board of fIealth, DISPOSAL SYSTEM CONSTRUCTION' PERMIT with the provisions of I0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated f ( . Approved Design Flow (gpd). Permission is hereby granted to;, Construct( ) Repa� Upgrade ( ) Abandon ( ) an individual sewage disposal system at er z 40 as described in. the application for Disposal System Construction Permit No. , dated' Provided: Construction shall be completed within 4 �e5f the date of this nert. All local co ' 'ons must be met. Form 1255 Rev.5l26 A. Solkin Co. Chadestown Date r ( i�and of Health /✓