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HomeMy WebLinkAboutSeptic App-Permit-Compliancer�. r r ' 2- Z 3 2 FEE 31 i�.2z-G)cb_ S\CDMMONW-F.-AET1-'OF MASSAC1-JUSLTTS Board of Health, , AIA, APPLIUMON FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct ( ) Repair Upgrade ()Abandon () ❑ Complete System D Individual Components Location () (_ Owner's Name Map/Parcel# Address 0 Lot# 02 Telephone# I T I - v! q Z- 5 Go--5q -.7 Installer's Nanle Designer's Naniqh On , Address C YY1 Address ......... . Telephone# �-� TelepllORe# - Type of Building u l Y1 Y Dwelling - No. of Bedroc Other - Type ol'Building No. of persons Lot Size �9V ,q, ft. Garbage grinder Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (lnin. required) 9140 gpcl Calculated design flow Design Flow provided 1 '�Qpd Plan: Date 03 1 7-02-2 Nlunb& of sheets _ _ � Revision Date ri Title '1_' D F Tq Hnmcr�' Description of Soil (s) Soil Evaluator Form No. Name of'Soil Evaluator TDoLL_'d:) WE. Date of Evaluation 2 2.d _2- DESCRIPTION OF REPAIRS OR ALTERATIONS S Pon The undersi ed agr es it st a abov desc i dividual Sewage Disposal System in accordance with the provisions of E 5 and further agree to n t t tem ' o on it til a Certificate of Compliance has been issue •by-tli B_6 'Health. Signed Date22— i ApC is G U4� Inspections CO��'10NW—L- L7Il OF MASSACH SETTS Board of Health, , jw"I. C Tl ICE C & COMP-LIANG-_ -il s b r f Description of Work: © Individual Component(s) 0 Complete System r U The undersigned hereby certify thaL the Sewage Disposal System; Constructed ( ), Repaired Upgraded (VrAbandoncd by: . at n­\tQ L-)(�c,iZ-- Or.,,r'L uCl. M()(144no Mprl has been installedItin accordance With the provisions of 310 CM 15.00 (Title 5) allcl the approved design plans/as^built plalls relating to application No. _pir� -" 0 19-Zciated 4A t'a)a. Approved Design Flow (gpd) Installer $� , M ���� 'h 1• 7 �C . 111 C � . -/ �" Y t e i Designer: -Dot a' Y hlspectoi'i, 1J The issuance of this permit shall not be construe as a guarantee that the sysil Dale: „•„ - 30- will £unction as designed. FEE COMMONWEALTH OF- MASSACHUS-1--' TS Board c f Health, MA. DISPOSAL SYSTEM M CONSTRUCTION PERMI - IT Permission is hereby granted to; Construct( } Repair( -Or Upgrade ( Abandon( ) an individual sewage disposal system at lv 0 '•-) ,-, as described in the application for Disposal System Constriction Permit No. 11;�),dated V_ Provided: Construction shall be completed within three years of he date of this permit. All local conditions must be nie€. Form 1255 Rev. 5196 A.M. Sulkin Co. Chadeslortn,y¢ Date ? Board of Health c