HomeMy WebLinkAboutApp-Permit-ComplianceFEE
00
No. E>90C-1'l-2l Com] &C i ILAt�" 60625' ' i
COMMONWEALTH Of MASSACHUSETTS
Board of lkalth, "Ct r'Mc ,; •1-1 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(,) Repair(-). UpgradeK Abandon( ) AComplete System ❑ Individual Components.
Location LthC, 110u,3 a ; c (,�
Rel
Owner's Name Jker (O, rv�..e-
Map/Parcel# -- j t/ Q
Address 1.7 o", MK
Lot# i -z
Telephone# 4 M -5-z,7
Installer's Name ` z4o
Designer's Name ii` ,n ry\fbv�C to r
Address X L
Address i2Wt r`,I JW
Telephone# _ _
Telephone# 44
Type of Building i �c .{'t �� S �'"'Q, "` `k i Lot Size I I +/—sq. ft.
Dwelling- No. of Bedrooms �Z-- Garbage grinder ( )
Other - Type of Building N A: No. of persons Showers ( ), Cafeteria { )
Other Fixtures ^l A
Design Flow (min. required) 334 gpd Calculated design flow Design flow provided 3 41 gpd
Plan: Date ( t -i I Number of sheets "Z__ Revision Date
Title P , ��c 75� Cil 0
Description of Soil (s) A1 (-.S t C: -2y
u 13 L.`s .12_4 - t 3 Z_ C- � �GL Scti,,� y4
Soil Evaluator Form No. Name of Soil Evaluator f_z k. ' f�LC71 �` ate of Evaluation 41 ti 1 01
5; (5- 15 Liz-
DESCRIPTION
iZ._DESCRIPTION OF REPAIRS OR ALTERATIONS iL' ► t I 6�X (3 I, S 4-0k 1 5-oa a 1 ST
5 GQ Gl\
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees not to place the system in operation until a Certificate of C plice has been issued by the Board of Health..
Signed Date 4,
ZQ10
Inspections
No.
COMMONWEALTH OF MASSACHUSETTS Ll 9
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) aComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded 4_)_Abandoned ( )
by:�,,,ee _
at s11C�1 a (✓�ics�Fccicn
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /4�- /)% dated 4�. - Approved Design Flow,.3 I C :Z (gpd)
Installer
C _--�
Designer: ''F L _ Inspector: Date:
The issuance of this permit shall not be construed as a,guarant'ee that the system will function as designed.
No. L..-�'Z�e-'_.t ��`--�� � FlEems-
47 / COMMONWEALTH OF MASSACHUSETTS
Board of Health, YOiar'�KW 'l• t_ MA.
DISPOSAL SYSTEM C®NSTRUCTI®NT PERMIT
Permission is hereby granted to;, Construct( ) Repair( ) Upgrade W Abandon{ ) an individual; sewage disposal system
at bl I'2-(,tY�d V1 -,A -,G 1'd. as described in. the application for
Disposal System Construction Permit No. / i- f , dated'
Provided: Construction shall be completed within thre'�bf tT e date of this permit. All local conditions must be met..
~Board of Health it k 'Y''
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Dated ! � � v" /