HomeMy WebLinkAboutApp-Permit-ComplianceNo. 13 TR - t q �S ()
FEE 4 61; 100
410
COMMONWEALTH OF MASSACHUSETTS AUN
Board Of Health, YA-gmo 0 n4 111,M.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT,—
Application for a Permit to. Construct() ) Repair( ) Upgrade( I.-A-6andon( OCompletieSystem ,,�vidualCompon,ents:
Location,
6D(A SG 0!S 3>-FaW E
Owner's Name RAROLr,
I Map/Parcel#
Address Ch 11=0UP-1 -e-A;okp;-_b]k 15'
Lot#
(P
Telephri
oeO
Installer's Name
Des ig ner's Name
Address
RA&pEE-
Address.;�8.5,1 yn4v
Telephone#
56�' — 44 -7-1
Telephone# 5w2 - 6,3 4-7
Type of Building Lot Size. �I, 7).5 3 '_ sq. ft.
Dwelling- No. of Bedrooms Garbage giinder.
Other - Type of Building ,No. of persons Showers Cafeteria
Other Fixtures
Design Flow (min. required) 3-30 gpd Calculated design flow Design flow provided gpd
Plan: Date " 115 1 -)LO (q Numbir of sheets Revision Date
Title- 5[ ]=o(jk_ SEA60(js j>W(i& se-xi—14
De . scription of Soil(s) Me) t L*A SAAOL-b � 43oct 1:5 s Z>LA,&)
- If
Soil Evaluator Form No. Name of Soil Evaluator HJ?LMCO�L Date of Evaluationwy 9 16(9
DESCRIPTION OF REPAIRS
The undersignedagrees to install the above described Individual Sewage Disposal System in accordance with the provisions, of TITLE 5 and
further agrees 0_potplace tern in operation until a Certificate of Compliance has been issued by the Board of Health.
Signe d Date S— 3 — I I
A
Inspections
No. FEE 25: n 0
COM MONWEALTH O� MASSACHUSETTS 0
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Ck 0/(0
of Hea
MA.
L- -'CERTIFICATE Of COMPLIANCE
Description.of Work: 5-f"vidual Component(s) El Complete System
The undersigned hereby certify that the Sewage Disposal-Systern; Constructed Repaired Upgraded (..4 abandoned
by: <?APE& -J (bw— x Ah-w-f-Al-N—ON. B Odb_ A,
at 51 F42 iL *aEA5,aj!; 1:)aj vE
has been installed inaccordauce with the
prf 3 0 CMR 15.00 (Title 5) and h,.e aWroved design plans/as-built plans relating to
9Aqsjoij
application No. d.ted��,- 7 0 Approved Design F (gpd)
Installer CAP&Wmfg /Ap�� 1Z 4b
A15MAX,'— -TPC- Inspector:. Date:
The issuance of this permit shall not be -construed as a gu,�
, e, that the system. will function. as designed.
No P:21 c - 9 _3_2� CA -Pao COMMON LTH Of MASSACHUSETTS
Board of Health, M" 0 VTT+ M.A.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( --)--Abandon ( )an individual sewage disposal, system
at ..:51 0,&) u as described in the application for
Disposal System Construction Permit No. dated eL�Z�_
Provided: Construction shall be <completed within-thT057e yes of date of this, al o ditions must be met.
a the. is permit, Al1loc c p
y
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadegown, MA Date � oard of Health