HomeMy WebLinkAboutApp-Permit-Compliance1146 € OU E 26 FEE ��. 6
No.
SO. Yc�lRAAO STH, MA 02664
COMMONWWLLA TH Of MASSACHUSETTS of
Board of Health, d ✓ MA.
APPLICATION FOP, DIS OSA '
YS
TEM CONSTRUCTION PERMIT
Application for a Permit to Construct (9�J Repair( Upgrade Abandon( - 4a/complete System ❑ Individual Components
Location 2')'- O -*A-lnn/
Owner's Name W e edea-
Map/Parcel# /� Zcaw 79 Q
Address Z6 MAI f
u j +
Lot# ! �'
Telephone#
Installer's Name V Pi to P, e.
Designer's Name
Address MA 1N S A -2M
Address d 54K ;7 L3
Telephone# el 8 - �ZG]3
Telephone# Z
1 y�
Type of Building Lot Size �sq. ft.
Dwelling - No. of Bedrooms Garbage grinder (-116
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
gpd Calculated design flow Design flow provided gpd
Plan: Date ` ! / �% Number of sheets Revision Date
Title /pp C
Description of Soil(s) (&tr
Soil Evaluator Form No. v Name of Soil Evaluator ��u «-r-:2!-r7 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
lP,
The under ' e agrees toVstafl�h;e above describedIndividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further es o not tp�lstem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Y DaT7:
"4.
Inspections
1 _f �T��j�jC,AL/t �T
No. C® O I'1' TH Orl 1°ll�SACH SETTS FEE
Br. I�th, Y M O U MA
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby c-erttiify that the Sewage Disposal System; Constructed ( ), epaired ), Upgraded ( ), Abandoned ( )
by: ki d i LIj d
at -Dn L P (-t �l
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. - 35'7, dated 7 -24 Approved Design Flow (gpd)
Installers e-Lt4l # ', V 1- 11%
Designer: t%j�(,'f/1iMIJF InspectorT1 (A., M Date: l __A Ee "."ice
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
- -
No. —4-t— Tor -1J P1 Qa FEES
Board of Health, yrt-(zB 0 Ui M MA. C
DISPOSAL SYSTEM CONSTRUCTION PERMI1
Permission is hereby granted to; Construct( )( Repair -) Upgrade( ) Abandon( ) an individual sewage disposal system
at ,DOLPN 1 tJ PJA4-1 as described in the applic4'tion for
Disposal System Construction Permit No / g �35- , dated 7--26
Provided: Construction shall be completed within three years of the date of this permit. All local1conditions must be met.
Board of Health
"Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date
"'ate