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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 02— / fo FEE V O y rs //tr CO 1�2OI� I ALT1I //DF 1 IASSACIIUSI TTS �C. C_ 6 l 1 &'j Board ofl7eall/a, Xl.' 0lUl APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION P11 --R SIT Application for a Permit to Construct( ) Repair( Upgradc( ) Abandon( ) - Ad<omplete System ❑ htdividual Components Locadon ,53 A p f Owner's Name Itjy C (— Map/Parcel# 3 C — lr 3 Address Lot# 7 J Telephonelt '� (p (� ' 9( 93 Installer's Name CANCO Designer's Name A / Address 350 Main Street Address —Vj1V1" 673 Telephone# Telephone# '7 "- �'j L Type of Building Dwelling -No. of Bedrooms Other - Type of Building _ No. of per Lot Size sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures �/ Design Flow (min. required) . �J V gpd Calculated design flow Design flow provided 3V6 o gpd Plan: Date Number of sheets f Revision Date _ Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS Aet- &A Date of Evaluation The undersigned agrees to ins 11 the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not t lac thL system in operation until a Certificate of Comlianc/e'has been issued by the Board of Health. Signed _ Date of Inspections No. .i -441 FEE COMIMONWEALT11 Of MASSAC11HNSETTS Board of Health, C/!kl©�/ �9 , PIA. 417 CEI1TIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (,),-Upgraded ( ), Abandoned ( ) athas been been installed in accord�4nce with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to application No.49_y � e7 , dated 11-J.2 e) 2-. Approved Design Flow (gpd) Designer: / h t, a'°%i Inspector: �„tr ...- The issuance of this permit shall not be construed as a//guarafitee that to system will function as designed. No. s" ` Permission is at COMMONWEALTH Of MASSACHUSETTS Board of Health, k°CG9F7/a, li , NIA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE ,,1, 4 to; Construct( ) Repair( t,.)-'TJpgrade( ) Abandon( ) an individual sewage disposal system as described in the application for Disposal System Construction Permit No. (/)— J� , dated f ,r, '✓ ( p"O Provided: Construction shall be completed within tluee-yr"ars of the date of this pertnit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Bulkin Co. Boston, MA Date ���fJ '� -Board of Health c