HomeMy WebLinkAboutApp-Permit-ComplianceNo. v� C'l-{ ���, is ov 1J "z✓ V FEE'
COMMONWEALTH OF MASSACHUSETTS
Board of health, Y.+fVltJli MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application fora Permit to Construct( Repair( OUPgrade( ;-Abandon( ❑ o ete System ❑ Individual Cm onentso
Location k'7 Cc'7 CtiN►0'1s
Owner's Name ► kq'i-el V -k�
Map/Parcel# 3 5'
Address 9 C� �•'ta/ S L
Lot#
Telephone# 0
Installer's Name Z ` t 13 ,�
Designer's Name _, S S cwmr-
Address�),-3Address
S' -
Telephone#
Telephone# Sa
Type of Building'"'' Lot Size �5� �sq. ft.
Dwelling - No. of Bedrooms Garbage grinder 1
Other Type of Building . x✓" / No. of persons Showers ( ), Cafeteria ( ).
Other Fixtures _
Design Flow (min. required) gpd Calculated design flow :3 S 3 Design flow provided gpd
Plan: Date M Number of sheets Revision Date
Title� �
Description ofSoil (s) Svc _
Soil Evaluator Form No. Name of.Soil Evaluator f- 5�� Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S E'to e�
The undersigned agreAs to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to p1a the sy tem ' o e do a Certificate of Compliance has been issued by the Board of Health.
Signed Date —:
Inspections
No. -5 UA D C �.. i t FEE
COMMONWEALTH OF MASSACHUSETTS - ci
Board of Health, A-gMQ(1D1j
CERTIFICATE Of COMPLIANCE
Description of Work: C7 Individual Component(s) wnomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedAbandoned
by:kna j
has been installed in accor a Ice with di provisio of 31 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. { dated l Approved Design Flows --(gpd)
Installer �� 1 l �d ami'. C G :'; i
Designer: ? ,la`s Inspector:.. t� Date:.
The issuance of this permit shall not be construed as a guarad//tee that the system will function as designed.
No. tL�~^7 FEE. .d
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COMMONWEALTH Of MASSACHUSETTS Ck—* 2.-o9i a
Board of Health, MA.
T T ,.
DISPOSAL SYSTEM CONSTRUCTION'- PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade,( Abandon ( } an individual sewage disposal system
at I C a19 C� 0)C ",):5 LC,, nJ V --'S R °. � � ct,ti j ; - (Y) C1 as described in the application for
Disposal System Construction Permit No. _;,; dated
Provided: Construction shall be completed within lime years of the date of this perrmt., All local condi' ns must be met.
Form 1255 Rev. 5/96 A,M.SulkinGo. ChaBestOwn,MA Date l oard of Health