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HomeMy WebLinkAboutApp-Permit-Compliancey No._azTc Y �," FEE' 116-rl 06 0>0 WDC -t9-35_51 COMMONWEALTH LTH OF MASSACHUSETTS Cho -Mi 2 Board of Health, Y, arWt)Ujh NIA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(bandon( - omplete System © individual Components Location 'IS M05COILI `t_J Owner's Name Mee `- r Map/Parcel# �� Address �r(7 M ch Lot# 14 Telephone# 120 11 ITLI Installer's Nam{e� r U �- e Des'igner's'Name �•r � + Address >�.1Jn� I T3 �/��W) ' Ei Address �6= Telephone# — _ Telephone# Type .of Building Lot Size gZ000, (lC� sq. ft. Dwelling- No. of Bedrooms 3 Garbage grinder Other - Type of Building No. of persons Showers (' ), Cafeteria. ( ) Other Fixtures. Design Flow (min. required) 0 I gpd Calculated design flow 33 1 Design flow provided d gpd Plan:' Date {�51 Z �C( Number of sheets 3 Revision;Date Title Desc iption:of Soil(s).A Ror I-znN mcl C 146ozol'J " ( A Jo Soil Evaluator Form No. Name, of Soil Evaluator WP- Date of Evaluation f> DESCRIPTION OF REPAIRS OR ALTERATIONS n— J.1) boo q QL The: undersigned agrees to install the above des 'bed Individual Sewage; Disposal System in: accordance with the provisions of TITLE 5 and; further agrees to not to place m in o n until a Certificate of Co=as been issued by the Board of Health. Signed Date— Inspections No. N D C 9 —35q ..3 COMMON `TIT OF MASSACHUSETTS o�0�`�� ��i ZI Boardof Health; VA r lV1lrXL'1 �l , MA. CERTIFICATE Of COMPLIANCE.. Description.of Work: ❑ Individual Component(s) U_Gomplete System s The undersigned hereby cer ' .. that the Sewage(D�isposal System; Constructed ( ), Repaired ( ), Upgraded YAbandoned ( ); by: i`6 rJ `� T� T �i 5_J - 0� Z C 0 -:IAj C.» at ,�-_ has been installed in accordailce with the provisions 310 :CMR 15.00 (Title 5) and the oved design plans/as-built plans relating to application No.Yy' , dated �/ Approved Design Flow (gpd) Installer C 3 s Q. Designe ve c- Pur, M nspector: 14 Date: The issuance of this:permit shall n be construe as a gu r. ee 04 the system will function as desk ed ` No. ':Jbk\pC'"�`�".i i + ` l.J ��IC� FEE 1 COMMONWEALTH Of, MASSACHUSETTS C 09-7 Board of Heawi, �%a - &Nou-F , MA. DISPOSAL SYSTEM[ CONSTRUCTION PETIT Permission is hereby gran ted to;; Construct( ) Repair( ) Upgrade (VV Abandon ( ) an individual; sewage disposal system at V SC-.OVas described in the application for p y /, r f �? . , datedr a . Dis osal S stem Construction Permzt No. i Provided: Construction shall be completed within three years of the date of this `t.`Allljo:cWcoitions must be met. Form 1255 Rev. 5/96. A.M. Sultrin Co. Chadeskown,MA D'dt�Board of Health( t,%