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HomeMy WebLinkAboutApp-Permit-ComplianceNo. Bo pG-l9-6o�b ,3 L !� ao _ G�oF E3 �`ss�o COMMONWEALTH OF MASSAC14USETTS Board of Health, yA'W-Iffli , MA. APPLICATION .FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct() Repair( Upgrade Abandon ()- t7ComPlete System ❑ Individual Components Location I� f i, eV h 4e%S / e% Owner's Name T ' e i n e j-swe J ,e1/i h Map/Parcel# 19-3 S Address a t't C -e.. Lot# Telephone# Installer's Name �' C Designer'sName Address 9,3 P��° Address q 3� ®� ;t' ll't7 rinP Telephone# S Telephone# Cct 3 6a HSt l I Type of Building' 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 y"1 Ad as 11_ Number of sheets Revision Date Title Description of Soil (s) s�" Sp t L G Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS ORALTERATIONS %J F . _ de 1�1 + klfb The undersigned, agrees -;o ' stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and, further agrees to no la a toa tii�on until a Certificate of Compliance has been issued by the Board of Health. Signed !1 Date Inspections , No. - -1' dO_Z�50 FEE J J' —, 60 COMMONWEALTH OF MASSACHUSETTS � /�,1 -7 Board of Health, Y _, MA, CERTIFICATE Of COMPLIANCE Description of Work:: ❑ Individual Component(s) Z :omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedixndoned by: at 4 41 C y -0J ✓i' has been `installed in afjco A c with �e r ,/ ions of 3 0 C415.00 (Title 5) and th a oved; design plans/as-built plans relating to w application No. `7ated'' Approved Design Flow (S'Pd) Installer Designer: !`, :�� t . i'41 PQ /. t ector; Date: The issuance of this permit shall not be construed as aaarantee that th stem will €unctign i COMMONWEALTH Of MASSACHUSETTS c"V (6G 17 Board of Health, y M,6 ]%r + MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to;; Construct( ) Repair( ) Upgrade Abandon ( ) an individual.sewage disposal. system at _ c_ e P �q r c twlt444 th ,l- i as described in the application for Disposal System Construction Permit No. /4'`/ 4—dated r/ Provided: Construction shall be completed within of the: date of this pel-MILAll local conditions must be meat. +. Form 1255 Rev. 5196 A.M. Sulkin Co. Chadestown, MA Datee Board of Health e_.