HomeMy WebLinkAboutApp-Permit-Compliance55)
No. iJ� P�\ 1'�O� "I'll",�r�, � FEE �v
C � C�1 N .STH Of MASSACHUSETTS
oa> d of f eaZCh; ' Dlm� MA.
P KATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair( UPgrade �bandon(❑ Complete System ❑ Individual Components
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Location 8161 c077A<,&
DR. Owner's Name A4ZSSAV
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Map/Parcel# _
Address
Lot# 13
Telephone# 9i7 - `,o5,,65:57
Installer's Nam ,
L + Designer's Name ,
d
Address °� �J
��` Address
Telephone# -
( Tlephone#
Type of Building
Dwelling - No. of Bedrooms
Other Type of Building
Other Fixtures
No. of
Lot Size sq. ft.
Garbage grinder
Showers ( ),'Cafeteria ( )„
Design Flow (min. -equir ) gpd Calculated design flow . Design flow provided _ gPd
Plan: DateNumber of sheets % Revision Date
Title 23 - OFOP �aJo
Description ofSoil (s) 10E'
Soil Evaluator Form No. Name of Soil Evaluator {1/D Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 7�0'Z.- U�r
Theunder ' a ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es to no to place sys in ' operation until a Certificate of Co plian has been issued by the Board of Health.
Signed Date
Inspections
z'
`,0,'
�y
Board ofHealth, _r "ODf MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) El Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ) , Upgraded Abandoned ( )`
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by: _ _
at— Y6
has been installed ip accordance with the provisions of 0 CMR 15.00 (Title 5) and the aper ved design plans/as-built plans relating to
application No. ��, dated t`
Approved Flolw ZZ gpd)' A
Installer -DA-iJ 3PP:,`�'Pi�ir'hr'i"
Designer: ]bat) MAN AN Inspector: z J ;102 &WZ Date: &21� ` /J!,
The issuance of thspermitshall not be construed as a gu tee that the system willfunction as designed.
No. -�` "'I 1."1� � �-) {�% � i``i 1J ? k_m p `o C60 STV FEE
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COMMONWEALTH OF MASSACHUSETTS IL1 5-7
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION HERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade,( -'S) Abandon( ) an individual sewage disposal system
at �C ��tl�r 1�fC as described in the application for
Disposal System Construction Permit No. / - "'� ated
Provided: Construction shall be completed within-43+ee-yMis of the date of this permit All local condition lust be met.
Form 1255 Rev.5196 A.M. Sulkin Co Choestown,MA Date Board of Health
J,S r f 3? . t�'P d,i ) f,�,��'r'i . /°--ma / d
91