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HomeMy WebLinkAboutApp-Permit-ComplianceNo. a �G— [-1�'r V -0 ` W I O G! FEE' -� =5% 0('-) OMMONW LTH Of MASS CITUSETTS Board o, f health, ��4✓a f T MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to ConstructVRepair( ) Upgrade( ) Abandon( - Complete System ❑ Individual Components Location 8 -Y %L E _- 1 Owner's Name o _ 1 0WLj A/ Map/Parcel#Address Lot# L p Telephone# tit / Installer's Name Designer's Name .SLj84 .l� jet Address ,04-1 1 Address . a C c Telephone# o a Telephone# o O Type of Building -sl d e i e Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures No. of persons Lot Size sq. ft. Garbage grinder {® Showers O, Cafeteria Design Flow (min. required) //D gpd Calculated design flow 3.3 o Design flow provided .3 XV gpd Plan: Date /d % - a o l F Number of sheets Revision Date Title Description ofSoil (s) ©-- 5 - Soil Soil Evaluator Form No. Name of Soil Evaluator A u L I c . ,e Date of Evaluation I e DESCRIPTION OF REPAIRS OR ALTERATIONS FA o'n r. s / o on GOC The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to pla thetem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed I", en AA I C�4V ".'rL Date _��O ' 02 0 r Inspections —Z �? .,. pit ` f f COMMONWEALTH -,.OF MASSACHUSETTS Board of Health, d , MA.�a // - �' �g 7 CERTIFICATE Of COMPLIANCEa Description of Work: El Individual Component(s) Q/Gmplete System The undersigned hereby certify that the Sewage Disposal System; Constructed (pr, Repaired ( ), UpgradedAbandoned by: at G!/ d1✓ % L= .Y/ ! .tif -r`--- `'! JrF/Ftri_ir. t 1'r �i• has been installed in accordan e with the provisions of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.. -I , dated w�~ r . Approved Design Flow _(gpd) Installer Designer: eb3( lei , Inspector:. rf �� /V-/ k' ,� Date: -1 Z i� The issuance of this permit shall not be construed as a guarantee that the system willfunction as designed. No. -o l (_• — 9— 6 q 9 Gam, .. B e.il l COMMONWEALTH Of MASSACHUSETTS Board of Health, Y / -a l9 -M Al i ,r -n+ , MA. DISPOSAL SYSTEM CONSTRUCTION- PERMIT FEE'✓ Permission is hereby granted to Construct(!) Repair( ) Upgrade Abandon( ) an individual sewage disposal system at f �;3t a � y, 1�' . , W,= "T-. t ,ia , —, as described in the application for DisposalSystem Construction Permit No. dated _ Provided: Construction shall be completed within .-,� • s of the date of this permit. All lqea ondtions must be;met. Form 1255: Re, 5/96 A.M. Sulkin Co. Chadeslow lhM ` Date; /x Board of He,41th %