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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 C� � � /A3 It - LD �` - �' �'�� o 1-7,83 FEE C0 ®NWEALTII OF MASSACHUSETTS (:u� Board of Health,ei oC(� rs�-�^ , MA.�- 1 APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(,) Repair( Upgrade Abandon( ❑ Complete System pZIndividual Components Location 'L `Z e �► r Owner's Name a h 4 -c ITL Map/Parcel# B " _ ©3 ,� Address 2 7Zeyd f► Lot# L, -f- $46 Zj7 d�96--S,-:�5r- Telephone# Installer's Name j5x mv)cz�'-Vc, Designer's Name Z& < < n Address Q P-eAe 2 �5 uCsL�LP Address Wt C -r JPS ilqe 12d Telephone# CG Telephone# !ia7 7- 01 Type of Building os-c.f ` d�N /-7 I Lot Size �7J %� sq. ft. Dwelling - No. of Bedrooms —J Garbage grinder( ) Other -Type of Building 41t -- No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Ailla Design Flow (min, required) 3 d gpd Calculated design flow 3 ?C) Design flow provided _ gpd Plan: Date Z2 % f �.� Number of sheets -a.. Revision Date q ,,� Title � g.�r�C� �`' � f / � � tQ `L Z2.O i') W (/ (2-" 7,3 o, c4A 13Cq� ( " I A- A t-5 Z 4 ' &0 & L -S to - ) 3 M —C ��' Soil Evaluator Form No. Name of Soil Evaluator L Date of Evaluation .5Bty 4--, fb4"k6fo 1 cvr DESCRIPTION OF REPAIRS OR ALTERATIONS &MGi-e- &C P -f-- /oryo a4 c (ill dp.r-r w 4-' 5 t-, ►-t-e The undersigned agree'to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees tq n�yoto pl a system in o e on until a Certificate of C 47 e as been issued by the Board of Health. Signed Date Inspect'ons l /'_•ll��J1%'1.•i7 dE`s `7=A• _,r:/, w.®/` -E7 d.: * -r tli'o/` 14 - CO�[MONW 1LIH OF,, I ASSACHUS ETTS2 r�? Board of Health; � ✓.tit c, -4, , MA � / CERTIFICATE Of COMPLIANCE Description of Work: Individual Components) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: pa'w l it i� 1- J x b --r) Q) r . at���.. ,�A�crfT has been installed in accordance with toe provisions of, 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to application No. dated 6 Approved Design Flow' (gpd�)/%� Installer t C-01101 4Sim`YP�itr Designer. i": hyC�1 i,1 1 W, (A){ ..S Inspector: Date: The issuance of this permit shall not be construed as a guar ee �Ith,em will function as designed. No. j3-'Sx�—� t �'"Il �t, FEE 73 COMMONWEALT14 Of MASSACHUSETTS Board of Health,, CA,tj-L. , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herebygranted to; Construct( ) Repair(, ) Upgrade(e Abandon( ) an individual sewage disposal system att as described in the application for r _ Disposal System Construction Permit No. / dated,M Provided: Construction shall be completed within<t4r-@,- ars of the date of this per i All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. CWdestown, MA Dat % Board of Health f