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HomeMy WebLinkAboutApp-Permit-ComplianceFEE 467y' �a pot�Dc-l9 a1�4°� C©�'[iMONWE.A1.T1:\1��,�,/},Iw1®�f MASSS�ACHUSLITS CQ�o`r760 _ l L7 Board ef Health, f(ti_+ MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System D Individual Components Location � %-� �4 � 1 Owner's Name (Z I, P-�, Ou P., C0'1,- --r0 Map/Parcel# Address ,� . •�, J 3 R luiC= "(3 Lot# 31 H Telephone# � .... L 5,30 Installer's Name & OUR, o Tjo (_ Designer's Name Address ® Fi O 1 �, Lvlt 11' address . (� : ( p� . 7, .Q • rt� Telephone# 5 ( Type of Building 0 L't' 1 ce ` ij`it-t) +4 Lot Size Gs. `jj sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other rixtures Design Flow (min. required) VZ r 9 gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets _ Revision Date 0 Title Description ofSoil (s) Soil Evaluator form No DESCRIPTION OF REPAIRS ORAITERATIONS < o o G m M.n to P Name. iA,AWA I C- '- Irl-t'eA!,11EN�17t rv-r^ Evahaator q &%,I Yo d }•iD09 Date of Evaluation 'two �UITC- V• Sn C) en? )% rl d -F .,A(Lf The undersigned agrees to mall the abo described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to pl %j1�}f!j�syste /o(�,eration until a Certificate of Compliance has been issued by the Board of Health. Signed ���-! �+—�'!r�i7 Date Inspections No (`,,o O`D-(e,_..01'4 ") FEE COMMONWEALTH OF MASSACHUSETTS Board gfHealth, MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed (j, Repaired ( ), Upgraded ( ), Abandoned ( ) ,4 9.:.:`a ri. i 1 1... rtt a r. ».. by: ) 7 11N at t - has been installed in accordance with the provisions of 31b CMR 15.00 (Title 5) and ahe approved design plans/as-built plans relating to application No. 17 - ti 4+r ° dated (^' P 4 1 �) Approved Design Flow "af "a ,,,,,approved r _ Installer C,{�"h Ti4"1)rm4e f? J� m Desi ner: � ex �r� �9 tri 5 4`9?,e,G" 1 :.' ° a `d' r2w.-t... ° tC`...-is", g 6 tt8 r s„ � 5 Inspector: ° ,G�,x,.f:.. as t`�Date: �'-�'� ;�f ,� r The issuance of this permit shall not be construed as a guarantee that the system will function as desiymed. No k:7 Cs 1') .k.+ i' - ,1 _.,f,.1 FEE � `�i(X, . ._ 9 (-e' COMMONWEALTH Of MASSACHUSETTS X4,-3 Board of Health, lld�' LLQ , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon ( ) an individual sewage disposal system at � :�etz`> ���� (g t � '�,t� 'y`��.� ";'"� � as described in the application for Disposal System Construction Permit No ( , dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5196 A.M. Sulkln Co. Chahslan, HA Date �)"`���°° Board of Health