HomeMy WebLinkAboutApp-Permit-Compliance-a -D- 00-7171
o ' 1 COMMONWEALTH OF MASSAGIUSETTS
Board ofHeafth, ViI I -Mau._, 1wil.
APPLICATION FOR DISPOSh SYSTEM CONSTRUCTION
JUN 10 2022
TH DEPT,
Application for a Permit. to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 3a, (k
Owner's Name d' L-0 Pftm
Map/Parcellf U
e C Go His-
Address 1~ C `o
Lot#
��•;--
Telephone# S --
Installer's Name
F2 I A02 'WIZS CD
Designer's Name
Address
Address
Telephone#
Telephonetk
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (min. required) _
Plan: Date ) 2-6, _
Title /'V-e✓64
Description of Soils) _
Soil Evaluator Form No,
J h
Lot Size—14-(-4j- sq. ft.
L ,i i ct'.. �✓--rr ;r <1 . ` Garbage grinder (/A)
No. of persons Showers ( ), Cafeteria ( )
0 gpd Calculated design flow
_ Numb�r,Pl'she4•rs .�
DESMPTIONOFREPAIRSORAI.TERATIONS
Name of Soil
Design flow provided( SI gpd
Revision Dae I\
F
F'Yt"'Z Date of Evaluation " _S5
1 - n
The undersigned agrees stall th above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to 11 p tfie tem 'tP'To i +tu til -"Certificate of Compliance has been issued by the Board of Health.
Signed d Date ee,� -"/-,"1 2
FEE 7
C'OMi'I'ONWEALT1I OF 1'IASSACIIUS],TTS
: Bomrl ofHenhA, IE, r FM G to
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System �
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, Upgraded ( ), Abandoned ( )
by: 1-1�11, 66f.
at �, r
has been installed in au
application No. 4
11—
hrstaller x/4-,
Designer:
The issuance of this permit
No. .....k• t
with the provisions of 310 CMR 15.00 (Title )' 'mid the
datedQ Approved Design Flow
Inspector: L..A.
h:dfl. not/ffhe construed as a guarantee that the system will
design plans/as-built plans relating to
Date:
on as designed.
p�
C'OMMONWEALT14 OF MASSACHUSETTS
TS
BoardofHeallh, � (/G`1i1 MA.
r DISPOSAL SYSTEM ''C(ONSTPUCTI'ON PERM
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( )an
as described in the
System Construction Permit No. eXc»' NLS dated f - AA ' L
'vc*c�r�^7t�. �
I: Construction shall be completed withimelnaee�yett+��of the date of this permit. All local conditions must be met.
:5/96 A.M. Sulkin Co. Choeeshyn, hlA Date 14 _ `gay ---Board of Health