HomeMy WebLinkAboutApp-Permit-ComplianceNo. lnc- le-ol J �aw _1 /_Oo l qe9 EEEA.
/ Q'_� 7 COMMONWEALTH OF MASSACHUSETTS c 13 q2fo
Board o
,rlealth,-rYl� t MA.
f IK <
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct()Re air() UPgrade6lJ/Abandon(❑ Complete System _alr;�vidual Co
m onents
Location '5 I Z7 PA(L7,21DC1E 11-ttLt-P P-0
Owner's Name Cn f - I S L. O FIL)-S
Map/Parcel# 2,ei / 10
Address S�1
Lot#
Telephone.# �
Installer's Name J FA✓MA"
Designer'sName b"q f it e/V
Address S SREA W �_d H/'1,j IC M
Address isOK *F l 54— DLJ I C H
Telephone# S69 4-32 S�-6S
Telephone# 2 2' jy? Z
Type of Building DLJ L3_ut - 4 Lot Size 2-0261 sq. ft.
Dwelling - No. of Bedrooms `f Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria.{ )
Other Fixtures
Design. Flow (min. required)
Plan: Date (12111
Title f �lWOM19
Lfq o gpd Calculated design flow
Number of sheets 2 -
Design flow provided 41Y $ ' t'2 gpd
Revision Date /✓�
Description of Soil (s) SEE P
Soil Evaluator Form No. 1 61 1 - Name of Soil Evaluator D (`I C�W_0- Date of Evaluation 6 12 �) I
DESCRIPTION OF REPAIRS OR ALTERATIONS IV8)
The ndrsign ees to inst ove escribed Individual' Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to n to pla th to operation until a Certificate of Complianc(�b s been issued by the Board of Health.
Signed Date / 09YO
1' 9
No. Le i C. �'°' � l f ` FEE 55, 00
COMMONWEALT14 Of MASSACHUSETTS
Board of Health,MA.
CERTIFICATE Of COMPLIANCE
Description of Work:. "dryidual Component(s) ❑,Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (}, Repaired ( ), Upgraded (°`Abandoned O`
by: S'"✓� ZFU�'(�4 v�t,vl L_ (. c
at 2 >) 2 "7 1//� 2 717 , iii V/ii..0 CL1 170
has been installed' accordance with the rovisions o 310 CMR 1.5.00 (Title 5) and proved design plans/as-built plans relating to
application No. � ? , dated - j', Approved Design Flow (gpd)
Installer /'
_41 ef
Designer: M&-U__kel s Inspector: Date: r:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
FEE `3iJ
COMMONWFALT14 Of MASSACHUSETTS
Board of Flealth, �Y$ �[�� �- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; .Construct( ) Repair( ) Upgrade ( abandon ( ) an individual sewage disposal system
at -2-012 Pat-11-LEYL� '. < <�'I 7'! as described inthe application for
Disposal' System Construction Permit No.7dated
Provided: Construction shall be completed within 4�ars� date of this permit. l local conditions rust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health