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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ` L1� � V, - \9 • -3 bo4t)c49-3,261 COMMONWEALTH OF MASSACHUSETTS (f ��Board of Health, , MA. r � FEE rAAY202019 'plication for a Permit to Construct(/) Repair( ) Upgrade( ) Abandon( - Ll Complete System �Tindivi ual Moi rftPT ill Location a Owner's Name no` �- ht --- Map/Parcel 2 2, Address a,30q f O Lot# Telephone# Installer's Name L.CJ OLt�- Desi ner's Name. g C'(yj rCtCI&v i n e Zit fl Address nci54qDLA a-- 633 Address (� IS 3 Sa 0oa��c� Telephone# S LI - Dag Telephone# _ o2S 8 Type of Buildings e - Of Dwelling - No. of Bedrooms a l �1(Sli�I Other - Type of Building No. of persons Lot Size sq. ft. Garbage grinder( ) Showers ( ), Cafeteria ( ) Other Fixtures S Design Flow (min. required) gpd Calculated design flow j!. Design flow provided gpd Plan: Date 5- - 30 1 q Number of sheets Revision Date Title Description ofSoil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agreestonot to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed P -t t , Q tt, it ie7— Date Inspections No. 6040 c--19-32-51 � �u'z\�����FEE' COMMONWEALTH OF MASSAC�TIS e-evl `�•� Board of Health, ` MA. ow` d-1r1f�'I 1[1rYd ' A'I T fill" d '�f'nX/Tlf T T A XTd11, Description of Work: CI Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedW, Abandoned at '"LC7-> iA OL -0-i- `9 has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. i / dated .Approved Design Flow =y gpd) , Installer 1) E tIJ� � I t1 i 3 Designer: W'4 " t-- 1 , Inspector Date:��' r,l The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. 30 c -�9 j�� W ,���� t 10 FEE COMMONWFALT14 OF MASSACHUSETTS ck,*32-9 Board of Health, ! //1 n l , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) UpgradeO `� Abandon( ) anindividual sewage disposal system at Z,5 �!©c.�t. dy .� , as described in the application for Disposal System Construction Permit No. �� ' dated . Provided: Construction shall be completed within s of the date of this permit. All local conditions must be met. Form 1255Rev. /96 A.M. Sulkin Co. Cha estown, MA Dat- -- Board of Health ---z F q(