HomeMy WebLinkAboutApp-Permit-ComplianceNo. O `D�OI-75— ER- 11`0013/7 FEE lS�w
COMMONWEALTH Of MASSACHUSETTS
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Board of Health, YA9&(� Ji�7' , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair UpgradeAbandon( - ❑ Complete System ❑ Individual Components
Location 43 y
Owner's Name
,1 1 e'L (1 u e n
Map/Parcel# OZ 71
Address q 34
' Q K o2-
Lot#
Telephone# .
Installer's Name EX 10►1
Designer's Name
g ..D
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C rrncn-}cx.) cst �
Address C G T F- �= G
0
Address
-
Telephone# . L 3
Telephone#�-0
g - 833
Type of Building e 5 i etLot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) C130 gpd Calculated design flow Design flow provided gpd
Plan: Date $ • 2 9 ' $ Number of sheets I Revision Date
Title
Description ofSoii(s).
Soil Evaluator Form No. Name of,Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS H Zo ) BOX - -Z t-i 7-0 .S®O 44 W L4 I SgOn f--
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.
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Signed 1C , 0. /?— Date 31 ' I
. Inspections �7_ f�VE'i1 t hf' sue, /� s o YS to /it 5
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No.; (�-LIFEE \>-�. LAJ
r � COMMONWEALTH Of MASSACH SETTS � � -77 (4
Board of Health, )'6flmQ UN , AL4.
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CERTIFICATE Of COMPLIANCE
Description of Work: ZIndividal. Component(s), ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired (v< Upgraded( ),Abandoned( )
by: o r\
at
has been installed ' accordance with the roviwo,_ns�o(ff*,31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. y dated '' -- P. Approved Design Flow. (gpd)
Installer k e_ra v.l t At 4-c �er 6 11._.. -)� t
Designer: , , % ,n fika n r"a Inspector: � � Date: _
The issuance of this permit; shall not be construed as a guarantee that the system will function as designed.
..3 A COMMONWEALT14 Of MASSACHUSETTS
Board of Health, Alem h iZM MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to;; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. 4"' ''` , dated
Provided: Construction shall be completed within r
Form1255 Rev.5/96 A.M.SulkinCo: adestown,MA Date) C B �/7 —oar
F t- ` r
,
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' as described in the application for
�Sf t ie date of this permit. AILWcal conditions,t lust be met.
of Health