HomeMy WebLinkAboutApp-Permit-ComplianceNo. �Q d/��1 -0073
"FEEIUSETTS r__.
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i "` � Board of Health, *M0j-11+ MA. JUN
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIOP -
I 1 p.Eprr
Application for a Permit to Construct( )`Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System 0
06
N
Location 3q ��
Owner'sName
Map/Parcel#
Address 360
Lot# e !
Telephone# r J f j( h r` � g
Installer's Name lYh
Designer's Name
,(Address Okr
Address C
Telephone# S
Telephone# S O
s
Type of Building Lot Size 87941P sq. ft
Dwelling - No. of Bedrooms 4 Garbage grinder
Other Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) l Id X 4 ! pd Calculated design flow Design flow provided '� gpd
Plan: Date d 1 a i'% A 2L j2I Number of sheets Revision Date
Title
Description of Soil (s) C;I e
Soil Evaluator Form No. Name of.Soil Evaluator k�vDate of Evaluation J�
DESCRIPTION OF REPAIRS OR ALTERATIONS I 3',e^P &A0 J-7 r— Llr,S) h &::l
The undersigned agree installthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and.
further agrees to o �,Plwdce sys a Certificate of Compliaaz,ce has been issued by the Board of Health.
Signed ' Date e;� a_ .�J ` "/&
Inspections ' %7 f a /�%l/i°Yif° zxl,ew l/ /�L�'�• �/ \
v — 3 y —1 � �'�� 1G rat..-►�,� G&��� E�'� A�
No S761 00
COMMONWEALT14 OF MASSACHUSETTS +v $701
Board of Health, yif►i 0 "1
CERTIFICATE Of COMPLIANCE
Description of Work: El Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded ( )> Abandoned
by:
at f rr r ,)c, cl CU ov o, ' I ic, �vg cv, :-1(7 M
has been installed ' 7accordance with the provisions of I.O CMR 15.00 (Title 5) -.h/id the a p ved design plans/as-built plans relating to
application No. dated Approved Design Flow ±. 6(gpd)
Installer i
Designer: Date:
The issuance of this permitshall not be construed as a guarantee that the system will function as designed.
No.� i ";9= 4J
fC6,! COMMONWEALTH Of MASSACHUSETTS
s> '`> � EMA.
;�r�' Board of Health, AM.
DISPOSAL SYSTEM CONSTRUCTION _ PERMIT
FEE,?
k =,3-701
Permission is herebygranted to;, Construct( ) Repair'( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 3 60 L&V% C f � r r I e -k as described in. the application for
Disposal System Construction Permit No. �- dated
-/--�
Provided: Construction shall be completed within t] e::y�rspo t date of this pert 't. All local conditions must be met..
Form 1255 Rev. 5/96 A,M,Sulkin Co. Chafes n, MA to G ��Board'of Healthr
._