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HomeMy WebLinkAboutApp-Permit-ComplianceGA Yl %Q"//� No.G� FEE .�Vv 2-0,0 -�79 COMMONWEAFTII OF MASSACHUSETTSok j4q Board of Health, I?7NVWi] MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(,X Upgrade( ) Abandon( ) - ❑ Complete System AIndividuall Components Location _ _ .��,. Owner's Name �E C - 4 p Map/Parcel# Address - -- - �-- Lott6 ' Telephone# Installer'sName _ _ Designer's Name �t Address t--._. Address Telephone# "; l� Telephone# Type of Building t l �i(-'i �i l L+a-'C I'm Size ((a Cn *f sq. ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil(s) Soil Evaluator Form No. _ gpd Calculated design flow Number of sheets Name of Soil Evaluator Design flow provided gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS ORALTERATIONS Z U S-rpk_._ m! 6-,k J C et.JC L'T i -N The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to no o place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed C Date a- - (n' a© COMMONWEALTH OF MASSACHUSETTS Board of Health, V°,rf f?P ()0_QA MAL CERTIFICATE OF COMPLIANCE FEE .' •✓,^^'VV c'fti � r 62 Description of Work: Aleutividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired % Upgraded ( ), Abandoned ( ) by ^i;." t'^t wt i L2° }t.t'Lz at 5" ° v has installed in accordance with the provision of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No 7 ` � r` �, dated - 1 ` � I-, t7%QApproved Design Flow (gpd) Installer ) k Ll CLrw f .. RI•' Ft AG' jT("--' (-_A",7'W[7VH- i2 _ Designer: LIJA Inspector )-' -4 ;:i r `" ✓r. Date: - The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. i° i (4"�+�'L"�."�^.C'?-'G-C CATtlr,.)1I"I* �C�. 1;„1 i, cz— _ FEE C®MM®NWEALTH °®F MASSACHUSETTS jr,lj � Board of Health, 2", q4 L A- MA. A ' DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(°t) Upgrade( ) Abandon( ) an individual sewage disposal system as described in thea application for at �' 9 ° g a li- s � (� �s-t ��l Ct ¢iFt i � P t _ PP Disposal System Construction Permit No. i l ] ti' , dated .j t P k � t`'s C) Provided: Construction shall be completed withit} three ,years of the date of this perm. All local -conditions must be met. C f, d .. Form 1255 Rev. 5196 A.M.6ulkin Co. ChOeMovo,MA Date board of Healt