HomeMy WebLinkAboutApp-Permit-ComplianceNo. 13 o �C-t�}- ?.i Z3 � �
2,— COMMONWEALTH Of MASSACHUSETTS
Board of Health, krxr oQ141. MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(v%Upgrade( ) Abandon() - D'Complete System 0 Individual Components
Location is ROW101ock COUt'i
Owner's Name ,
Map/Parcel# 71L — 149
Address $ O lar\ i
Lot# G Z
Telephonel#
Installer's Nameti {3" EXeQV�-� j p�
Designer's Name G rr� ASo
Address
y ca5crr oc'c5-�a1la..lc_
Address
Telephone# 5-0g, _ OG
Telephone#
Type of Building' e etc �n-� o. Lot Size sq, ft
Dwelling- No. ,of Bedrooms Z Garbage grinder (
Other -Type of Building No. of persons Showers ( C �eria ( )
Other Fixtures T
Design Flow (min. required) Z Z O gpd Calculated design flow Design flow provided $ 98 gpd
Plan: Date Z Z 3 19 Number of sheets Revision Date
Title
Description of Soil(s),
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS N Zo _D BOX - Z - H ZO .SoO qa I LI C
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 Lt Date Z Z �' 9
'!j::. Inspections
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AW
No. 6 04V C 19-2-12-3 /t
COMMON 1LT14 Of MASSACHU I TT (o
Board o f Health; Yo� i m o�.-i �, , MA.
__
�� CERTIFICATE Off` �'OMPI-LAAKE
Description of Work: 5r1'.diyidual Component(,) D Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( j, Repaired ( UpgradeAbandoned ( ).
at Q u_j 1,a *, cal (2c):J r" 7
has been installe acc rdance with the ro��sions of 10 CMR 15.00 (Title 5) and thh proved design plans/as-built plans relating to
application, No. `�� dated Z /7. Approved Design flow(gpd
Installer X C a 1.Jg i a � �
Designer: ___0 � UC_ r t t 5c� ✓'a Inspector.; t �J Date:
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
�7 {
No. G""{ 725 [j ,CA V . FEE'
COMMONWEALTH OF MASSACHUSETTS
.Board of Health, Tarte OO -4.. , MA.
DISPOSAL SYSTEM CONSTRUCTION _PERMIT
Permission is hereby granted to Construct{ ) Re air(�Up� ad Abandon an indiAdual sewage disposal. system
at ` 0c)) _Q t,a cNCL COO V-1— as described in the application. for
Disposal System Construction Permit No./ `Z /, dated �7
Provided: Construction shall be completed within ih�� e. date of this, p� rTit, All local conditions rriust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date : / Board of Health � �