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HomeMy WebLinkAboutApp-Permit-Compliance` No.' ^llav7 /10 /> !�— IC� FEE 00 COMMONWEA. T Of MASSACHUSETTS Board of Health,MA: APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for Permit to Construct( ) RepairA Upgrade( ) Abandon( ) - ❑ Complete System 41dividual Components. Location Z & Acy(sgY Owner's Name K4P45,j Map/Parcel# aq"1 Address t©( SL . litJDSa� ��' Lot# Telephone# Installer's Name�� �� Designer's Name Address ! Address Telephone# 50!i —22 -Z Telephone# Type of Building�(�l+`164-(� Lot Size sq. ft. Dwelling- No. of Bedrooms Garbage grinder Other - Type 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 C.t— lVtSe-.) �4 - l t7b_ The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further,agrees to not t lace the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections No. o N tC-I� —C�3�� cam. C+C) /� �II,I 1//FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, 1ALX40 (,� -1-1 , MA. 0�1 CERTIFICATE OF COMPLIANCE t Description of Work: Xjndividual Component(s) O Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded ( ), Abandoned O' by: QA06V2t (6,CXZ It r at �Q � tl,�U�, has been installed in aa ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. /'f — / - , dated, % " /!Y . Approved Design Flow r� (gpd) Installer d kAA� , ;r n1 -,r Za, yi tL 42-n Designer: Inspector: Date: _ The issuance of this permit shall not be construed as a gu. tee that the system willfunction as designed. f / COMMONWEAL� MASSACHUSETTS Board of Health,ykp-„&0!2� , AM. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE, I - Permission is hereby granted to , Construct( ) Repair A) Upgrade( ) Abandon( ) an individual sewage disposal system at- a s 4i%`} A-e,r.1 as described in the application for Disposal System Construction Permit No/ e dated Provided: Construction shall be completed within thx-oe years of the date of this p r it. All local conditions must Form 1255 Rev. 5/96 A.M.,Sulkin Co: Chadealown, MA Dat__� T Board of Health` _ , Rlr '