HomeMy WebLinkAboutApp-Permit-ComplianceNo. C'F' C.'G t58 F—0057SCI- FEE
COMMONWEALTH Of MASS C14USETTS ck#39 V
Board of Health, MA.
�/SAPPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( - W Complete System D Individual Components
Location �/ O v
Owner's Name T
Map/Parcel# 023 �!I!
Address / 14-j,9
Lot#
Telephone# �o
Installer's Name
Designer's Name
Addresso
9 � T tiv�� B�eoo
Address A a„ 3 -54E = Gu,� 1I
Telephone#s-c,� dj oj�� o /� f/
Telephone# _5-0? 3p'S-- 6-9 o
8A559` - -570- �6 y' — - 5 % o soo ,
Type o ilding L.ot Size / sq. ft.
Dwelling - No. of Bedrooms Garbage grinder (A�O
Other - Type of Building, No. of persons Showers O,Cafeteria ( ).
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 33 O Design flow provided gpd
Plan: Date .3 —o2l _ 610/7 Number of sheets Revision Date
Title
Description of Soil (s) — 7 �/. % .� �i ,mss' �i'� �oq,�,� s�1 YS'- /// G �%s✓E` -59. J
a/
Soil Evaluator Form No. Name of Soil Evaluator �(p,Mi) wrLe_�� Date of 6L 0 Evaluation !
DESCRIPTION OF REPAIRS ORALTERATIONS (a.)w 1 &0EW1 i7'L�� S 1a7i t yC.z r C /S%/ t%r C�- 4
WA
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 to place the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed (��� f,Q, oe Date
No, �)� +Gy.. ! FEE
_. - COMMONWEALTH OF MASSACHUSETTS cj .�
r�- E
Board ofHealth,®t i , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s), [omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed k'), Repaired ( ), Upgraded ( )> Abandoned ( )
by:
at
has been installed in accordance with the previsions of 3 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.. � '7 , dated .7 -7 Approved Design Flow ? (gpd)
Installer
Designer:LY �y e "ru Er ` r, lr Inspector: k Date:`
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No.
Sc� c FEE
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COMMONWEALTH OF MASSACHUSETTS &A �►�-�
Board of Health, t 0(_, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct(/ Repair( ) Upgrade( ) Abandon( ) an individual, sewage disposal system
at 't%`���„rf� Ie /ri 1l� .� �.� <7'/,1:�.,�u l` as described in the application for
Disposal System Construction Permit No.% 7 ` , dated
Provided: Construction shall be completed within f the date of this permit. All local conditionsanust be met.
Form 1255 Rev. 5196 A M Sulkin Co Chadeslown, MA Dat / ? . f Board of Health �f c _..�<' �/' z--
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