HomeMy WebLinkAboutApp-Permit-Compliance49-0 �/V ✓�-�Y i 1� � b ! _V� C/-7 1 FEE
COMMONWEALTH Of MASSAC14USETTS ck*
Board of Flealth,MA. �✓
A)A"WiICATION FOR DISPOSAL SYSTEM � �NTSTR TI6N � ,��
Application for a Permit to Construct(_ Repair( ) Upgrade( ) AbandonO �'Comple ya �d /V. t al po uts
Location #62 d 9114..4 i i
Owner's Name L ' yq �T 1^ 1 Irl Cs
Map/Parcel#
Address,�.
Lot#
Telephone#
Installer's Name {Z1L _
Designer's Name
Address PO.� Ill Yil F%1i°!,
Address
Telephone# —
Telephone#'
Type of Building els . - Lot Size 4/0, t sq. ft.
Dwelling- No. of Bedrooms Garbage grinder {
Other - Type of Building No. of persons Showers( ) , Cafeteria ( ).
Other Fixtures
Design Flow (min. required) 33h gpd Calculated design flow Design flow provided 391 gpd
Plan: Date�Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. &j4Z-t j,, Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
Then
dersi ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ees to n t to p _ e the m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
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41 2 -
Inspections
No.y' � S
COMMONWEALTH OF MASSACHUSETTS
Board of Health,V4Q MA.
CERTIFICATE OF COMPLIANCE
FEE d�Ci•V
. I -72,`j
Description of Work: 0 Individual Component(s), 5 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired ( ),. Upgraded ( ), Abandoned ( )
by: L- ` S"t-r=ya' C -(-) �'-7T-eA ) c, 0M
at /, 7 tri of) 1W-,-1 r', R1 -S (Z4)
has been installed in accorda e with the provisions of 3I.I1 CMR 15.00 (Title 5) and the roved design plans/as-built plans relating to
application No. , dated ed esign Flow (gpd)
Installer (c� �".` - ! J�. � �+ ..�'
Designer: ,')t" i�J �al C, {_' t=', 6 10. Inspector. Date:
The issuance of this permit shall not be construed as a, guar ee that the system will function as designed.
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No. (✓ .l � 3 C �1 %`, _ . i K '`/t ..'-a. __.1.5i.,,..— i i7 FEE 44,
COMMONWEALTH Of MASSACHUSETTS
Board of Health, - YMMQ UD , MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual, sewage disposal system
at 6, 0U, Fb\ N P (5 d as described in. the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed withirr�elys bf the date of this pp twit,, All local condi} ns must be met.
Z -
Form 1255 Rev. 5/96 A.M.Sullk'inGo. Chadeslown,MA Dat 4 --Board of Health