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HomeMy WebLinkAboutApp_permit-ComplianceNo. 0ow- 1-Cm31�� 8- ` � I�6'�.. FEE ��) „ � " COMi[M[ONWFALTH OF MASSACHUSETTS / Board ifHeallh, �V {i(OZ�T%f MA. APP'TICATION FOR DISPOSAL SYSTEM CONSTRUCTION '.RAI7,E_E9 A lication for a Permit to Consniucr. Re air U trade Abandon - CYCom teteS stem ❑ ad 'd' uaI'LPP O P O Pb (� O P Y � Location Owner's Name Map/Parcel# J C(Address 3C- („A •p Lot# is Telephone# ilr�t -�S�• _ e y Installer's Name ,r. "^O ..---- 'kC , �r Designer's Name AddresA� V\ Address . , �-• L \ Telephone# Type of Building -z<-. . � Lot Size Gael (?, sq. ft. Dwelling -No.of Bedrooms 7, Garbage grinder( ) Ocher -Type of Building _ No. of persons Showers O, Cafeteria ( ) Other Fixunes Design Flow (ruin. required) gpd Calculated design flow Plan: Date to(t�t.s Numbirofsheets_ Title Description of Soil (s) _ Soil Evaluator Form No, Design flow provided -3 gpd Revision Date Name of Soil Evaluatorh.M8a•1 Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS U.? '"( . Wit. ...__.\.,-.. X_ �,( rdcA'lS tss'rci 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 peraton until a Certificate of Compliance has been issued by the Board of health. Signed Date (<�, y, Ou-er� ( U - 01c:. Sct.IS GK- -19 TL"�r nQ�-o <`arQ.0 accvtM coe. No �a i i'�'(...') R ....- ; FCL COMM ONWEALT14 OF MASSACHUSETTS Board ofFlealtla,7! 1I MA OlL CERTIFICATE OF COMPLIANCE Description of Work: O lndividual Component(s) ©,Complete System 1;'Z2� ( y The undersigned hereby certify that the Sewage Disposal System; Constructed . ( ), Repaired ( ), Upgiaded ( ),Abandoned( ) ,...__.. 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 application No .i° -;.;; > f'r. , dated f�''' k lr `i . Approved Design Flow (gpd) Installer '�:'•.• .. `.. �, 'A�. �s , ti <-- `�_1,,^ Designer: f44+�,eba. ' hhspector: Date The issuance of this permit shall not he construed as a guarantee that the system will function as designed. No. R,,oQ tprpy_rl"% Mfr ,.ry COMMONWEALTH OF MASSAGIUSETTS Board ofHeaItIt, O1, °1. MA. DISPOSAL SYSTEM CONSTRUCTION I�RRMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade(,,)` Abandon( )an individual sewage disposal system at Disposal System Construcdon Permit No. dt ":rt , dated o / as described in the application for 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. 6uINm Co. CtatlesinerM1 Date 14.)�`ht �#G, Board of Health