HomeMy WebLinkAboutApp-Permit-ComplianceNo. ��%,�_I I��Zi� ��..0 Z-Q--Q:.i FEE � 55, 00
COMMONWEALTH OF MASSACHUSETTS ck-*2-233 ,
Board of Health, _ J MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - W2omplete System ❑ Individual Components
Location 941
W I tid Q vvsE i? Q
Owner's Name j—oe p^vidci
Map/Parcel#
Address 7 1 14,er- rw r,q I ✓1 e IZ jr,'-D h of ki
Lot# 7
Telephone#
Installer's Name SO �y` lAh� o�
Designer's Name Dd tvh C 19e 1? h ' I t1 e e rI h
Address
& C IC e -rum a S L,IC tt
Address 5-31 Mmmif SY, V"—YMjY u Lt
Telephone#
50.? 776 g<6-?
Telephone# 50 it 3 r,
Type of Building () Ure It A'A o Lot Size 5 G O Q sq. It,
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 U` gpd Calculated design flow 33 O
Plan: Date �l 19 / 1 j Number of sheets
i� t
Title
Description ofSoil (s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow provided 3 y cJ gpd
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s no tg,gI ce the system in operation until a Certificate of Co pit= a has been issued by the Board of Health.
Signed' Date 9 / /
Inspections
No. upc- I,5-I-72SC®MM®NWI;ALTIT OF MASSACHUSETTS ` FEE o�
Board ofHeallh, f Asa' ont , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System t,' ,�i
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgrades yy Abandoncd ( )
by:
�`,D'
at Zt ttVbCYIE iZ�
has been instilled in accordance with the prow ision of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. l.�'a F / dated.. Approved Design Flow (gpd)
Installer tJ
Designer: BOOP CIhrPry C✓ *ih C%— Inspecto /- Date: -2
The issuance of this permit shall not be construed as a guarantee l 4te function as designed.
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