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HomeMy WebLinkAboutDOC004No. W© �CD�7 _0057 317 f FEE' 72- COMMONWEALTH Of MASSA 14USETTS Board of Health, ) LA1@MO tM MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT plication for Permit to Construct( ) Repairk) Upgrade(-) Abandon(] ❑ Complete System 4,1ndividual Components Location 2 `S" U((/v Lw „5 "14i�At9UIt j Owner's Name B126b /J v Map/Parcel# 43 1 WS- Address S� Lot# Telephone# Installer's Name �� i��`v t/�/�S Designer's Name C)•^/ (_ )1 (.. (^ L Address j ^�� L - j Address FD. 6 ox" ,265� / Telephone# S"a� (4-3 Z 5 Telephone# i17 u U Type of Building _A)CLt- �' � �i Lot Size sq. ft. Dwelling - No. of Bedrooms 4 Garbage grinder( Other -Type of Building No. of persons Showers( ),Cafeteria( ) Other Fixtures Design Flow (min. required) 144 O gpd Calculated design flow Design flow provided 44 % gpd Plan: Date sh ft Number of sheets / Revision Date Title Description of Soil (s) jri!F 1%(Aa/,/ Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation :DESCRIPTION OF REPAIRS OR ALTERATIONS Q'W '1 ,S 1 / -2 /Wm� �(D C,,,W,5 "X �, �iC 7 � le, -1-77.2/ �,�` %,ll�?59 h . 17 SC FEWM Al. Mill ►sem The uees to inst ve described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and further ees to of to pl a syst in operation until a Certificate of gompli ce has been issued by the Board of Health. Signed Date V No. Cca4".Ct Ic' 0 FEEJ �V -.COMMONWFALT14 OF MASSACHUSETTS AS � Board of Health, yft9N0Tr1A, MA. CERTIFICATE Of COMPLIANCE Description of Work: h 1`ndividual Component(s) O, Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded ( ), Abandoned ( )' at ` 1 SiNI QiZ !) L -AN has been installed in accordance with the provisionjs of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated �>I—ijApproved Design Flow (gpd) Installer Designer: Inspector: &0 A Date: The issuance of this permit; shall not be construed as a guarantee that the system will function as designed. No. y ( c_••149- -t `.)y / P FEE � 00 COMMONWEALTH Of MASSACHUSETTS Board of Health, Y{ =&o o7} , MA. DISPOSAL SYSTEM CONSTRUCTION' PERMIT Permission ishereby granted to;Construct( ) Repair( ) UpgradeYD Abandon( ) an individual, sewage disposal system at ;) i 4'x 1 o�L4", as described in. the application for Disposal System Construction Permit No. dated :2 /. G',� T Provided: Construction shall be completed within_ Ns o the�P date of this pe mit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chalestown, MA Date �1 ,d t ;i' ,+ Board of Health' ` � �✓ 9' zac._ _