HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE' (1�
3 � COMMONWEALTH LTH Of MASS C14UU-SETTS (b ?
Board of Health, Y O tm+ „MA. <
APPLICATION FOP, DISPOSAL S STEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( Upgrade( Abandon - U eolm fete System O Individual Components
O P (J Pg ( () P ys P
Location i L L, e (- R
Owner's Name �C � CZ -1 X/
19E`R'S� C LZCP
Map/Parcel#
Address ;rI�Z
Lot#
Telephone#
Installer's Name CAW l 0 P
Designer's,. Name " G W (z(&YG& C. AJGr �
Address ' S3 CORk 5T HNC
Address A2,5
Telephone# <Q 9- -9 Ft-771
Telephone#
Type of Building R ES e.1T i A— _ Lot Size , 9
�- � f $t�4,� - s ft.
Dwelling - No. of Bedrooms Garbage grinder(
Other -Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min, required) A 3 o gpd Calculated design flow Design flow provided 343,4 gpd
Plan: Date S - t'S S Number of sheets Revision Date
Title
Description of Soil(s) 7`0 cr nCN
Soil Evaluator Form No. Name of Soil Evaluator i P iM W-7- Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -TW!; tit r.[_ AJCLU k-10 IS00 64-0 -00 -5" 7Vr(C: TK4jV- `ri
W t\.t) 14 - to 0 - 4 o Y, ?17 (5) 14- (b Cu tMA ;I. , ear- 1(-� LE�2 6�-?� O Al 6VO5
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 to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections p
!? FEE +
COMMONWEALTH Of MASSAC14USETTS �s 3UI')f
.� S
Board of Health, Y .®I} MA. -`
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Components) flj,Romplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded Abandoned ( }
by: 0-AVEt&t7 5 t QN.I5kE'QAZQ ik1C k4Rt> ` Ac
at. IL 5 L4K6xI&• _x2
has been installe in ac ordance with the rovisions o 310 CMR 15.00 (Title 5) and the app oved design plans/as-built plans relating to
application No., !` .% dated. Approved Design Flow (gpd)
Installer CAmAjib&6l�?�QP'}�1 �3.1 Cl ,R.�
D esign e r: -Tc- Eyjdr &-&V C.Cz --na C.. Inspector: 443h54D41jDate: Z z hz
The issuance of this permit shall not be .construed as a guarantee that the system will function as designed.
No.
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y A aft) (R-A MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
FEE oO
;I ! 9-7
Permission
,.is.herebygranted to;, Construct(- -) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
14 at L'V-6if-I6 AQA;0 5o VTbA V44Agw1-q-4 as described in the application for
Disposal System Construction Permit No: , dated ?-Iff le.
Provided: Construction shall be completed within. caeca bk date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadealown, MA Date Board of Health /, '`