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HomeMy WebLinkAboutApp-Permit-ComplianceaL- D Tl? I y- oo/416 No. - 1 —01-q0 FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair( ) Upgrade andonO - ❑ Complete System dividual Components Location C' y) Owner's Name Map/Parcel# /� Address -S;C Lot# Telephone# Installer's Name - I i 1S (3� C04 Designer's Name koyl-1) . V. 61 br71v Address a3h Address, ash - Telephone# Telephone* S OiY 72 5- e% 60' Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms 13 S� Garbage grinder( Other -Type of Building No. of persons • Showers( ), Cafeteria ( ). Other Fixtures Design Flow (min. required) 3 gpd Calculated design flow -. Design flow provided gpd Plan: Date ��!/7 �� Number of sheets Revision Date , Title Description of Soil(s) `�e Ted 160 + Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation of ,� DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agre to install the above cribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to to,*p1 a the Atp til a Certificate o �omplia ice has been issued by the Board of Health. Signe Ze, Date Inspections No. 6o 1): '� w{�� i FEE ,^1 COMMONWEALTH OF MASS CHUSETTS Board of Health., WA0 11A , MA. CERTIFICATE Of COMPLIANCE Mex , Description of Work: dividual. Component(s) O Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ),,Upgraded�Abandoned ( ) by: ^ I c t i � a\�/? �t G?rit� 1��YF bra ( 1 `i lot- r4- t. l ??') f� . ��:,i has been installed ' > accord ce with the prejviserns of 1O CMR 15.00 (Title 5) andtha proved design plans/as-built plans: relating to 4., " application No. dated. Approved Design Flow 'T7 (gpd) Installer ' .v { ;', cr; ,4 Designer: iU im 't td Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. hop PC-if3 -ol cj D FEE - COMMONWEALTH OF MASSACRUSETTS Board of Health, -am ©( rf:]A^ MA:. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission ishereby ranted to; Construct Repair( Upgrade Abandon( ) an individual sewage disposal system ygp at CC-j `) t Qti f as described in the application for ��..//, Disposal System Constructiorbk'ermit No. ° dated I Provided: Construction shall be completed within three years ofthe date of this permit. All local condit ota§ must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA D'dte�-1 Board Of Health J/r