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HomeMy WebLinkAboutApp-Pemit-ComplianceNo. �,�--2-o-Co3311 FEE `��� )CI - CONI MONWEALTI-I OF Ali ASSAC14 JSETTS Board r f flecdth, 'YAP -840011+ , MA. APPLICATION FOR DISPOSAL SYSTEM, CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System O Individual Components locationU Owner's Name _ Map/Parcel# Address 16 Lot# as described in the application for s Installer's Name Desig'ner's Name �.. Address �%� J Address �"" c 1/, /✓� Telephone# ,_ �`r' Telephone# Type of BuildingLot Size sq, ft. ,Ar Dwelling - No. of Bedrooms '_T,, Garbage grinder,( Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixurres Design Flow (min. required) gpd Calculated design flow Design flow Provided _17b gpd Plan: Date Number of sheets Revision Date Title Description ofSoil (s) Soil Evaluator Form No. `" Name of Soil Evaluator Date of Evaluation DESCRIPTION OFREPAIR,SORAITERATIONS 11 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further apxes to not to place the system in operraa%on until a Certificate of Compliance has been issued by the Board of Health. Signed`f=l�/l� /,i �/ " Date brspect:ions ZV 20 o il t c Oy7,5�-- No ) -'E.IkM(..`.it_(^i 12tli FEE 4,'�-.�''i (y) COMMONWEALTH OF MASSACHUSETTS Board of Health, MA, tjt CERTIFICATE OF COMPLIANCE I; Jl "" 1 0 Description of Work: Cl IndividualComponent(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired O, Upgraded O, Abandoned ( ) Y at , .�=i' t ! ::.��-� _a ,� toe 'Al v...*P / s`'v ' .t ,x. i r has been installed in accordance with the provisions of 310 CMR 15.00"(Title 5) and the approved design plans/as-built plans relating to B ,^ application. No A/, r„`� dated �? °R'�.,?�r 4 v° Approved Design Flow 0L^ (gpd) d Installer f`l'441,4"'"1 . - Designer:_vv,�s,��.::°_� �''.,"w1a+= Inspectort. T"t weal...,"t1.frC_... Date: 717,/L-20 .. The issuance of this permiVshall not be construed as a.guaramce thaf'the system wilt -function as designed. No. �A 1 ^��%ia'. �( � P:� C A`tA5A7 101, COMMONWEALTH Of MASSAC14 JS -EFTS Board ofHealth, �1'`-P-LOBt�f�`�' ,MA. DISPOSAL SYSTEM 'CONSTRUCTION PERMIT FEE J%a. �»!r) ('.iM�.(tit Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system f at ' rTP as described in the application for Disposal System Construction Permit No. P' cn� 95d, , 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. ChadeoeR MA Datell'), I ; k.... ? Board of Health %_1 R'R