Loading...
HomeMy WebLinkAboutApp-Permit-Compliancet(a5l //pyo \ y� A%/l 1✓ d lr�lc Ria ,4�.y 5` ,. �51 y(�� C- ��-bZ1X� B G✓rG� y J A/L FLS i JO7 C®Ni MONWEAL II ' BIAS AC IIJSI �S c,P 3 39 / i sl ,.-•; � y � v Board of Health, l/y/4 NIA. t Y a ! �s �G'! �'C APPLICATIONFOR DISPOSAL SYSTEM CONSTRUCTION RI:RMf'�.- Application for a Permit to Construct( ) Repair( Upgrade( -) Abandon ( ) - Cl Complete Systen>)A Hndividual Components Location -LGYf Owner's Name .e 2-2-0 P) l Map/Parcel# f Address S > A-' e _- Lot# Telephone# Installer's Narne6ggyy,,�"��� Designer'sName �J� C Address �p J( G � 9 '54" ""Ic' e Address / l /1.7 i4 ,,.t 5-7 G;4, ,' Telephone Telephone# jl(f / Type of Building Dwelling - No. of Bedrooms Other - Typc of Building _ Other Fixtures Design Flow (min. required) .5-5 p� C3 B gpd Calculated design ow Plan: Date (-"� �� G Number of spec Ls Title Description of Soils) _ Soil Evaluator form No. OF ORALTERATIONS -e ct cc, Name of Soil Evaluator 'ek ( No. of persons Lot Size 3 A' ' -e sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation 4 10L The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees yqot to ph system in operation until a Certificate of ompliance has been issued by the Board of Health. Signed /j Date T- - - — 1; No 1 t 1 P. x i �.. C i L,7 ( 4;x.4 qe' r.'�;. Ea;�aS;d`t ' COMMONWEALTH ©L' MASSACIIIJS�� S _ Board ofl-leallly ki'v,U f` J„= Ag MA; ” < CERTIFICATE OF C®NIRLIANCL <t r Description of Work: )®�Individual Component(s) ❑Complete System C -W R/ , p' , s? ff "'e n f �JA V The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (;;:), Upgraded ( ), Abandoned ( ) by: at ,has been installed yinn at application No. r -,e Installer !'K..-', with the provisions of G3�,10 CMR 15.00 (Title 5) dated 44'-," `.r` rrY Approved Design Flo Designer: ( ,'k-)i..a,'1 t ..° The issuance of this permit shall not )7 No Inspector: the approved design plans/as-built plans relating to Date: be construed as a guarantee that the system will function as designed. " FCL COMMONWEALTIL OF MASSACHUSETTS ck A� 1 Board ofHealth, tF '"-'' ='r°'0 DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade.( :)'` Abandon( ) an individual sewage disposal system at Ii t_ eV1 _., r .e" Disposal System Construction Permit No. !`"' 7, dated 1'h as described in the application for Provided: Construction shall be completed within three years of the date of this pent t. All local conditions must be met Form 1255 ae,.5/96 A.M. Sulkm Go.. Chades=R MA Daterrrv`A � ``01 Board of Health t n of.... _.o i ,✓ F