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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE' v" i go-Dc-13-333� COMMONWEALTH Off` MASSACH USETTS Board of llealth, VMMWN kmI P , 5- APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(.YAbandonO - Cl Complete System Ed'Individual Components Location G (— VT -- 10 CAS-1 Owner's Name JK I M —om Z7Z- Map/Parcel# q � 913 1' Address r ' Rd. G A uT LU l\l A W Lot# l r? ej 1' 0 C7 1 go's g Telephone# SA — J , ­-.5M Installer's Name ��R t`'i Q , Q .(L, _L Designer's Name BASS ,U-p— c- ,yd 4zerw Address .0 ,1 jy. �j 3 9Z!1 QVV C1 Address P- ®. 9 04- 1163 E, . o.J Telephone# S -- L► _ Telephone# .. t _ q o ,_j Type of Building Lot Size al I a) sq. ft. Dwelling - No. of Bedrooms Garbage grinder { Other - Type of Building No. of persons Showers ( ) , Cafeteria { Other Fixtures Design Flow (min. required) / % 0 gpd Calculated design flow 3� (� Design flow provided gpd Plan: Date �b L Number of sheets Revision Date Title Description ofSoil(s) 09/Cj O C-177- a tjC-'' ©AA �v C'j'-�C'i SAS. Soil Evaluator Form No. Name of Soil EvaluatorAMV VO N �� Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS `�'NSTQO"� I3e, -� 1 1 N �Vtfr A�U 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 t9,place t stem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed_ Date / /�k( P� (�� ^ ,� J No. f✓Ci 1 � i J 9 ^ 33 � � � E�>,) z COMMONWEALTH O SSACHUS ETT w Board of Health, )�U4D i n24 MA. �312311$ CERTIFICATE OF COMPLIANCE: - Description of Work:, %W- dividual "Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradeandoned ( ) by: o j`@ t" at t.,.. rf c has been installed iwccordance with the provisions 9f>310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated dated. "T "> ! . Approved Design Flow -(gpd) Installer r "T C3 (Z , S, Ai-C, n � C_� S,, f ; P wal,LJ� Designer: U5 RI i%e—t F04, Inspector: k Date: : �J The issuance of this permit shall not be construed as a guar tee that the system will function as designed. j`�iµ_.� '?i% / t 6� �� FEE .. No; COMMONWEALTH Of MASSACHUS ETTS Board of Health., � aw w l MA. DISPOSAL SYSTEM CONSTRUCTION' PERMIT Permission is hereby granted to;; Construct( ) Repair( ) Upgrade( --'`Abandon( ) an indhidual sewage disposal system at (,� t ct' K �: ruf %as described in. the application for Disposal System Construction Permit No. he'i �'1 �, dated %_�- h . Provided: Construction shall be completed within three years of the date of this permi•'v. -local conditiorks lust be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chailestown, MA Date i Board of Health