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HomeMy WebLinkAboutApp-Permit-ComplianceFEE S.5 n QOtvD4-2O-2,c72,-7 C©MMOlNWEA'LTH ®F MASSAC+IJUSETTS ,D Z52-- Board if Health, YI-b9V )4=Mb MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct.( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System 0Individual Components Location L ` vSo U7C4 Owner's Name Map/Parcel# €,( P b Address &q , C- bQ. (X -NA. Loth 110 Telephone# Installer's Name vdyzCT .OUQ C()•TAIC Designer's Name Address J>� l�S� (}sKiJ ttr•'_%���>�e AddressR, (7, - �.,� c,MISMc,- Telephone# Type of Building Dwelling -No.of Bedrooms Other -Type of Building No. of persons _ Othcr Fixtures Lot Size q7 sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design Flow (min. r quiz .d) 5 3 (� gpd Calculated design flow 0 Design flow provided _ Plan: Date t ��.��faOt3LO Number of sheets_ 3 Revision Date Title � Description ofSoil (s)Ot//�IR ¢iO{-}Z,c`,nl�'^�.l7P Arm 3-s r H r Soil Evaluator Form No. Name of Soil Evaluator tf✓E( 0 A DESCRIPTION OF REPAIRS OR ALTERATIONS : _�Q ) ) 6 gpd �l -�✓„[111!m J�Nr�r Lf bate of Evaluation a' i - c CoaC) W The undersigned agrees to instal a abov described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to plattem�rationuntil a Certificate of Compliance has been issued by the Board of Health. Signed Date a I7a'Zwri Inspections ( o X51,}C. f_) M^ d? �) a�.. t FEE No. COMMONWEALTH I.TH OF MIASSACHUSETTS 1 Board of Health, VrWrV )1)-n4 MA. d Jr `) Ding (Q 2J CERTIFICATE OF COMPLIt�NC�� Description of Work: ❑ Individual Component(s) 0 Complete System - r 01 The undersigned hereby c r)tify that the Sewage Disposal System; Constructed ( ), Repaired Upgradedf es , Abandoned ( ) by: at has been installed in ace " /qulance with the pro 7sig5ns of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to application No. `- [„z �' - dated / d � Approved Design Flow t:7, (gpd) Installer DesgnetX ,Inspecrchs aliR €6 �Yg !, �„. �w� [' Date: The issuance of this permit shall not be construed as a euarantee,thatthe q stern will function as designed.