Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceNo. C-lU'V18� / bTk .`q,,CFO ��+ OMMONWEALTH OF MASSACHUSETTS FEE 114oardofllealth, �© l , MA. /J Z -12-e A APPLICATION FOP, DISPOSAL SYSTEM C ONSTRUCTIftNPERIM01�1 Application for.a Permit to Construct( ) Repair( ) Upgrade�andonO ❑ Complete System CI -Individual Components Location U -r4 Owner's Name I f+6 0U4-5 ._ agaJ& Map/Parcel# 3 Address O Zl Cly !�:" Lot# Telephone# Installer's Name 7 AddresstJ t Designer's Name: - Address Telephone# 50-9-4-77— Telephone# SO Type of Building )eum A4 Lot Size sq. ft; Dwelling- No. of Bedrooms Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ), Cafeteria Other Fixtures rq, o +� t7EA-rs Design Flow (min. required) X30 gpd Calculated design flow Design flow provided :35!%,2. gpd Plan: Date Q' S" d—LO ( T Number of sheets Revision Date Title D. Q uA-Pjfad 'S -Qu- ' Y/�oL 1 L ry Description of Soil (s) it Soil Evaluator Form No. Name of Soil Evaluator at Date of Evaluation A- /!o "AO -LE DESCRIPTION OF REPAIRS OR ALTERATIONS USG GM---rts.-� lia:2 i CseGCVd ���TICr't+ rLTil 1w A— 2162,0 The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and further agrees to plac the system in operation until a Certificate of Compliance has been issued by the Board of Health.. Signed Date Inspections ��"1. / b cJ�JsC (f ►��L'� CC� ®t���� t No. Board of Health, �Yj2tI,����- CERTIFICATE Of COMPLIANCE Description of Work: 0 Individual Component(s) Q+W'mplete System 1"71 The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgr; COMM NWEALTH OF by: _,C at Ik 0, zqlf , Abandoned ( )' i has been installed in accordance with the provisions 9,k 3MCMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. datedA� Approved Design Flow pd) s Installer �- Designer: C' J61 i.3F 'C 1 — Inspector: Date: The issuance of this permit shall not be construed as a guar tee that the,system will function as designed. No. ntS ""0 VE ' -7 i•^4b' ev) 6'D E7 FEE . .� COMMONWEALT14 Of MASSACHUSETTS Cil -2,3G 'f VA&M olm:k Board o Flealtlt, "' � �=y�1` DISPOSAL SYSTEM CONSTRUCTIOT. PE614-- Permission is hereby granted to;. Construct( ) Repair ( ) UpgradeS< Abandon ( ) an individual sewage disposal system at -,:�kC K-eimp KOAZ 150�UT14 YAQAkami as described in the application for Disposal System Construction Permit No. "moi' , dated_'%. Provided: Construction shall be completed within for at of the date of th, e nit. All local conditions must be met:. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chakstown, MA,�i •//Date Board of Health- i