HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6001%C " 1/ 4x- <-- FEES�5 --�
COMMONWEALTH OF MASSACHUSETTS
Board of Health, "0 , MA. FR��
PP LIC TION FOR DISPOS L SYSTEM CONSTRUCTION PER 3 2019
Application for a Permit to Construct( ) Repair( iUpgradeO Abandon( ') - ❑Complete System AIndivid"DEPT.
Location
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Owner's Name e -L -I rPo-I) 5` Aji)
Map/Parcel#
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Address :g V-15KE MIZI L A�vYpi aei &iA
Lot#
Telephone#
Installer's Name € a -i
Designer's Name V CA
Address
Address
Telephone#
5562 —tt--z Z — F52 7-7
Telephone*
Type of Buildingl ��ZCl G l }�-� Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Tvpe of Building No. of persons Showers ( ),'Cafeteria { )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. _
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �' s 7-44z_ GU6-Lej k4 -Y— arrrI4 A1,'0,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no lace,ffia system in operation until a Certificate of Compliance has been issued by the Board ofHealth.
Sighed Date
Inspections
No. �o i� �� .-iC(_ 2S5 A�A
V-411/
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COMMONWEALTH LTH OF MASSACHUSETTS 4 �
Board ofHealtla,UL� , MA.
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CERTIFICATE Of COMPLIANCE
Description of Work: x Individual Component(s) ❑ Complete System���
The undersigned herebyce tify that the Sewage Disposal System; Constructed O, Repaired ), Upgraded ( ), Abandoned ( }
by:� O ct)
at :3A b(2/E1v6G DIRT &E-
has been installed i ccorda ce with the prov�ons A31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 17�1 / dated.L r . f Approved Design Flow (gpd)
Installer- (be R P,14.+4�
Designer: N 1 Inspector: Date:
The issuance of thispermit shall not be construed as a,gu r tee that the system will function as designed.
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i - COMMONWFALT14 6f MASSACHUSETTS _ A -J. � s c- 19
BoardofHealth, AA ocx-r -f- MA.
DISPOSAL SYSTEM CONSTRUCTION , ERMIT
Permission is hereby granted to; Construct( ) Repair(x Upgrade( ) Abandon( } an individual sewage disposal system
at
as described in. the application for,
Disposal System Construction Permit No. /f-// 7 , dated 5-% f !L.
0(
Provided: Construction shall be completed withinAh-ree years of the date of this permit. All local cpnd' 'ons must be met.
Form 1255 Rev. 5/96 A.M."SulkinCo. Chadeslown,MA Date, / Board of Health -1