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HomeMy WebLinkAboutApp-Permit-ComplianceT No ® 7t FEE 651 owq l /j�f®NWTI �ICIII�ETT� Board of Health, yi {Z(V1017 MA. APPLICATION FOR DISPOSAL SYSTEM N TRUCTION PERMIT Application for a Permit to Construct( )`Repair( ) Upgrade(�andonO - Complete system O Individual Components Location 14a. Lpo_ ot, Q—, Type Owner's Name _ 40AM !t 1 Y. -c'n� Map/Parcel# f J Address/ q.1 6N . f'®� ©r. i I�,,r 1 C 7V A A Lot# L Telephone# si Installer's Name Designer's Name RA C' S Address 5 .tel t1 OI(_, j M(� Address Telephone# Telephone#Ll— of Building Lot Size }- IS sq. ft. Dwelling - No. of Bedrooms ?i Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ), Cafete�;ia ( ). Other Fixtures w " / GU7 Design Flow (min. irequired) % %L5 gpd Calculated design flow 330 Design flow provided �. gpd Plan Date Number of sheets .3 Revision Date Title Description of Soils) Soil Evaluator Form No. Name of Soil DESCRIPTION OF REPAIRS OR ALTERATIONS -"/'j b.<Q-I1 j S©0 Ci Crj;IO0 "4rtit t rJ- 13Q r ---S The undersigned agrees to install jhe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5and further agrees to n lace t . in operation until a Certificate of C mp 'atice has been issued by the Board of Health. Signed Date 1 Inspections No.Q�1� dpi g U0�` �J COMMONWEALTH OF MASSACHUSETTS O Board of Health, 91L 4 �-IK.f�k l , MA. 0 CERTIFICATE Of COMPLIANCE Description of Work: 0 Individual Component(s) -complete System The undersigned hereby certifyAat the Sewage Di osal System; Constructed ( ), Repaired (,,Upgraded ( )> Abandoned ( ) by: �� u t '� 1 UK co. at Er, rt has been installed inccordan ce with the provisions 310 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to application No. _ f l - j' dated. � Approved Design Flow (gpd) Installer `� i' 17 r U iz- c - Designer: b1\5-) i1yalL wc-,j P Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the ,system will function as desig-ned. y ok �� e, t No Tr "o �`kb C i `1 - �i CI tom. FEE tit ` t t 1 COMMONWEALTH Of MASSACHUSETTS Board of Healtli, AR4&A6QT4 , MA. DISPOSAL SYSTEM CONSTRUCTION. PERMIT Permission is hereby granted to; Cokruct( ) Re air(✓`) at "I r'� to r' Po h� ' . �. - --9 Disposal System Construction Permit No j�? ` � / , d; Upgrade( ) Abandon( ) an indh idual sewage disposal system as described in the application for Provided: Construction shall be completed withinrs o t�e date of this permit. All local c ditions must be met. � X Form 1255 Rev. 5/96 A.M. Sulkin Co. Chabstown, MA Date f' Board of Health