HomeMy WebLinkAboutApp-Permit-ComplianceNo. �I"t -' 1q---�-boS o 1t UML,-1(- xou FEE LW
CO IMONWEALTH OF MASSACHUSETTS
SETTS
Board tfHealth,
_AP
IV10111 }+ MA.
09 ➢PLICATION FOR DISPOSAL SYSTEM, CONSTRUCTION PERMIT
e(.pplication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) -IGoinplete System ❑ Individual Components
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Location / n orolc
Owner's Name
Map/Parcel# L
Address it, N
Lot#
Telephone# D �. 77 G ,
Installer's Name (,. L,� �' ��
Designer's Name
Address pov
6
Address
Telephone# 7LI-'Z4- 69U
Telephone# .. ` - S
Type of Building r r a Lot Si2C I /Z06� 6 sq. ft.
Dwelling - No. of Bedrooms F/ Garbage grinder( )
Other - Type of Building �P Ley No. of persons Showers O, Cafeteria ( )
Other Fixtures �
Design Flow (min. required) [7 t! U gpd Calculated design flow WO Design flow provided t/-/95 gpd
Plan: Date i',.,jJ /Q 12 1.0 Numberofsheets_ti Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OFREPA116ORALTERATIONS I^S'�`' t r� Fp.F_�'!Lpr—4Z
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance been issued by the Board of Health.
Signed Date �S//`1 aoA
No. 7:.`i.) 6;0 )" �.(...a„,(r a OL- FCL Tw"a`:A (la.!
G ,f COMMONWEALTH BOE I SSACIIUSETTS$F;tr (
Board of Health, ' idl-l`='d"4i01714 MA.
CERT JEICATE OF COMPLIANTCE -2;,Iola �,r>
of
Descripiion'of Work: l] Individual Component(s) , I Complete System ,,
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded �;`+*�, Abandoned ( )
by. pr 1E6 ,. LG G� f ,a bar C xi
v g gg `,qq
at
has been installed in accordance with the n'ot rolls of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. °' rte` rr , dated ` 5' r*.. ``e Approved Design Flow t IV (gpd)
Installer A L - N r C
Designer: Dt — s6;=a s"--*rarer,Ilr.-, Inspector (,�`" N _Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE e `j � O0
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Healll,, ° Z,,410:. , ,VSA.
DISPOSAL SYSTF I CONSTRUCTION PERMIT
Permissionisherebygrantedto; Construct( ) Repair(;) Upgrade,(V', Abandon( )an individual sewage disposal system
at P � a ¢ ' fps; l`°lX as described in the application for
Disposal System Construction Permit No. / "'dated V�
Provided: Construction shall be completed within.thre o 'tlie date of this permitpAll local conditions must be met.
,� Boardo£Health
Form 1255Rev. 6/900..M. &ulNin Co Ch99RAtlN0.6A{� Date �