HomeMy WebLinkAboutApp-Permit-ComplianceNo. 00"1q— G FEE 60
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l q-� COM ON LTH Of MASSACHUSETTS [
Board of Health, MA. ,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct() Repair(-) Upgrade/Abandon( -.�Com pTete System ❑ Individual Components
ocation
`j (p p:5T
Owner's Name _':,C Amo �( �
ap/Parcel#
Address so R- sJ 5-0-07-Y di
1Lot#
1 00
Telephone#
Installer's Name �d - Q aVF =Vc
Designer's Name a� t7 0&,/N •TAJC.,
Address S
e7 ��- % { ���-�
Address nZs4 Ili R
Telephone#
50S_q-7-?_g&--(7
Telephone# .502-a-73 r Q'S -7
Type of Building (ZEST s#-- I.ot Size sq. ft:
Dwelling - No. of Bedrooms S Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) 9'80 gpd Calculated design flow Design flow provided L gpd
Plan: Date 3-0 a - aD i 4 Number of sheets Revision Date
Title f4=, :50ug 4 Y®¢R#qp Lj- mG-i
e�
Description ofSoil (s)
Soil Evaluator Form No. Name of.Soil Evaluator M r p1 �f Date of Evaluation oZ -afa �aQl�
DESCRIPTION OF REPAIRS OR ALTERATIONS T N ST79-LL 14-2.0 21000 6'�/ &) « TD -'V- lb
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to no place ie system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �"__. Date 4 l
_Inspections
As
COMMONWEALTH Of MASSAC14US ET
Board of Health, ymmem34 , MA• � ' -
CERTIFICATE Off' COMPLIANCE 0J�II�
Description of Work: ❑ Individual Component(s) ®/Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( )> Repaired ( ), Upgraded (,Abandoned ( }
at _-5--r :54%mhl YARazowni
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) arld th p roved design plans/as-built plans relating to
application No dated.!* % 7. Approved Design Flow (gpd)
Installer ;'JOA _17
Designer: Ins ector: - Date:
P _ _ --
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.��1f- " 1 `) ( .. FEE
COMMONWEALTH Off' MASSACHUSETTS 11 P �
Board of Healtlt, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct � ) Pg Repair( Upgrade( ( Abandon an individual sewage disposal system
P � � g P y
at 5 { S .S / as described in the application for
Disposal System Construction Permit No.. `� -�(� dated'"
Provided: Construction shall be completed within tkee-yrs of thdate of this per nit. All local conditions must be met.
.moi _ ,� �/ 1 i
Form 1255 Rev. 5/96 A.M. Sulkin Co: Chadeslown, MA Date? f ,° board of Health - /J