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HomeMy WebLinkAboutApp-Permit-Compliance-0 0-3 q Z(a COMMONWEALTH Of MASSA . HUSET'. c07 61 Board of Health, YAeM1)(%- , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(,.)) Repair( ) Upgrade( ) Abandon( ) N Complete System © Individual Components Location 31-1 (W H Owner's Name ° CSD Jeg Map/Parcel# ci ~� 1 '� Address 1, Lot# Telephone# 50c6 a3 'j �j q 2 y Installer's Name �C ( Se:PJ Designer's Name JA- Address 5j!s lob a+�. e,,jwt, AL owl Address 1573 A4,4. st 1Jfeti.�2; Telephone# 5'0 Telephone# !�0 16, &i - Type of Building (� e, Sr JC, Dwelling - No. of Bedrooms Other - Type of Building Lot Size 146 0 y sq. ft, Garbage grinder( No. of persons Showers ( ), Cafeteria Other Fixtures Design Flow (min. re uired) �'�� gpd Calculated design flow `0 �® Design flow provided Ss gpd Plan: Date ,� 1 rl'If Number of sheets I Revision Date tt / Z .I Title Description of Soil (s) C Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of.Soil Evaluator Date of Evaluation -� 3•acV 2.Czt `T The undersigned agrees to install the above described. Individual Sewage Disposal System in accordance with the provisions -of TITLE 5 and further agrees t not to place t e stern in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date (2/i1 r i i s Ins ections-! 1/Q'` d 0 - S s� ��w _ ,/ii�s /�is7�S/ 7`�1 rev .� f/�- �/1-rJ %cam®� a i '!� 1,.,.A l V!. /tel. n/. -=/S _ /6 A loi a ✓/o Le ,-I!f 4�- Af1AZ)//L//-& - llk-WD''.f&l No, E-` �"'-i�-1 1',' ` ! FEE C®MMONWEAI.T14 OF MASSAChIJSETTS Board of Health, YA o vr�4 , MA. D a CERTIFICATE Of COMPLIANCE Description of Work: Cl Individual Component(s) Yomplete System The undersigned hereby certify that the Sewage Disposal System; Constructed' Repaired( ), Upgraded ( ),Abandoned( at has been installed in accordance with die provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. pp '; /%, dated �' .. j , . Ap roved Design Flow ,�e. < (gpd) / Installer �.� ����"t gf�.t { c=� c� %. `.✓ .�c-f p... -54 i G41/1 Designer: It« -1 W-4 Inspector: The issuance of this permit shall not be bonstrued as a guara COMMONWEALTH OF MASSACHUSETTS Board of Health, ".41Z Yjr i1 , Nm - FEE i ;n), C) 0 -- (1134- t.. k DISPOSAL SYSTEM CONSTRUCTION' PERMIT Permission is hereby granted to; Construct(r" ` Repair( ) Upgrade ( ) Abandon( ) an individual sewage disposal system at 51 `, ftX,-; as described in the application for Disposal System Construction Permit No. -;el , dated Provided: Construction shall be completed within thxe-e ge'a'rs of t e date of this permit. All local conditions must met. Form 1255 Rev. 5/96 A.M. Suakin Co. Chadeslown, MA Date !�� ` ar / Board of Health '— j tf ". y' .f k