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HomeMy WebLinkAboutApp-Permit-ComplianceNo. •�Jlr tt L ��" / FEE', 17 d COMMONWEALTH Of MASSACHUSETTS CAW 1515 (6' Board of Health, )(&gM©(?TVf MA. RECEI ED APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PEVMIPR,2 4 2019 Application for a Permit to Construct( ) Repair(,.)e�pgrade( ) Abandon( ) ❑ Complete System Ja'.[tidivi cal DEPT. Location 1 S"P* 1/UN Ave Owner's Name 90$(7 WM 114:_kOW I Map/Parcel# Z ^ Address Gl %'W(L''1S V A`t Lot# Telephone# Installer's Name S tFd✓(/" AA_tV QC(,4VW711V Designer'sName O Address S �j�A Lt' -,,1-4-7 Address Telephone# Lfn S—fts- Telephone# Type of Building' ow bit -I ry5 _ Lot Size sq. ft Dwelling- No. of Bedrooms' Garbage grinder Other -Type of Building No. of persons Showers ( ); Cafeteria Other Fixtures Design Flow (min, required) gpd Calculated design flow Des ign provided gpd Plait: Date '— Number of sheets Revision Date Title Description of Soil (s) Soil Evaluator Form No, Name, of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS FCVW iN � '�) M(.= FA4-''1 1 `0UJ r '70 S— 1 L 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 e- em in operation until a Certificate f Compliance has been issued by the Board of Health. Signed. _ Date r Inspections ��[}��I g� � �(�( � T .FEE f� ® (' In Board of Health, ARM00134 , Mui. CERTIFICATE Of COMPLIANCE Descnpiionof Work: _Q410vidual Component(s) ❑Complete System --� The undersigned hereby certify that the Sewage Disposal System; Constructed ( ); Repaired ,,Upgraded ( ),Abandoned by at has been installed i a�c`• dd ce with the �r0 sions of 310 CMR 15.00 (Title 5) Sand the approved design plans/as-built plans relating to PP -1— »' application No. dated �.� .Approved Design Flow (gpd) Installer Designer: -- Inspector; Date:. The issuance of this: Permit shall not be construed as a guar tee that the system: will function as designed, No. d� -280 I �aNP1� r�r� \. b FEE' A J, COMMONWEALT14 Of MASSACHUSETTS CL* l 45 (o Board of Health, %e Q Unf , MA. DISPOSAL SYSTEM CONSTRUCTION. PERMIT Permission is hereby granted to Construct( Repair(j Upgrade( ) Abandon( ) an individual sewage disposal. system at 67 =' ' i; 'v 1/� �(! ��� as described in the application for Disposal System Construction Permit No., dated or ..� Provided: Construction shall be completed within three years of the; date of this perm*. . All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Date'`) .;;� � /9 Board of Health