The URL can be used to link to this page

Home My WebLink AboutApp-Permit-ComplianceNo. 0✓ FEE 'b C®MMONWFALT14 OF MASSACHUSETTS C 5-&q`i Board of Health, �CL r ►�'l C7tT �-4'� , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct( Repair( UpgradeVJ�AbandonO - ❑ Complete System (Individual Components Location ' GY?WLP- Zg Lhn 1'S -7 u Owner's Name 1 Z(o 1 SCLSS J?- %Z ro.i R c t Map/Parcel# 0 — t Address % G£h) �a �as*a�^rMA'QZ31 Lot# Telephone# Installer's Name 13, A, 3 rv-x-) Designer's Name c � '1 ��rn U�GTr1,y kwC Address l7z © 1 � Cev1 -�CwJ11 Address Z W Curs S ��1� (2J FcJ (-) to oJA Telephone# 0 ?': QQ-"Z 155( Telephone# s - -n j ©2(o'A ( Type of Building 1 a �L k Dwelling - No. of Bedrooms �J Other - Type of Building Other Fixtures Lot Size - RO - sq. ft. Garbage grinder () No. of persons Showers( ), Cafeteria ( ) Design Flow (min. required) �® _gpd Calculated design flow '357 C Plan: Date l © N Title d C Description of Soils) l Soil Evaluator Form No. Design flow provided �y V-4—, Tlat� Name of Soil Evaluator Si tS"/Z DESCRIPTION OF REPAIRS OR ALTERATIONS /7 "t C,S 'r— C k Q VLA ✓S "T S d �C The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a o not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Sign Date No.L � 61-k �Y s / FEE 00 C®MMONWEALT14 OF MASSACIIET � �� ►�� Board of Health, Y<-,cfL,-u .r � � MA� 02, CERTIFICATE Of COMPLIANCE f _X11 Description of Work: ;Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded ( ), Abandoned ( )' by _ , Ar y at Q E- G- i I� t;.�% �. �` ..?� t^n �Ct.l(- _ ( .1 -7 Ck "* has been installed in a corda ce with the provision s of 0 CMR 15.00 (Title 5) and pproved design plans/as-built plans relating to application No. f dated /�O OA ,ed Design Flow 7`70 •(gpd) Installer , 7 PJ rJC �t`C'��Y[itti Designer: l- i -o' IMPr-,it-rt Inspector: 41!9 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. .. No. 9 ; i'l t� C. - (� -�' C, l�_U� t FEE Via.,0 COMMONWEALT14 Of MASSACHUSETTS z4� 5 2.W4 Board of Healtlt,�� DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade 4(,Abandon( ) an individual sewage disposal system at Z i u,,4 c Ci;'L�a v; rw (�j Jw kS �T-rl"( CAas described in the. application Tor Disposal System Construction Permit No. dated';r Provided: Construction shall be completed within -d4 ars of the date of this err All.local c�di ' ' � p p n 'ons. must be met.. Form 1255 Rev. 5/96 A.M.;SulkinGo. ChaBeslown,MA Date .� ✓'4� Board of Health G.r- i.