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HomeMy WebLinkAboutDisposal System Application/Documentsy 1 ( � A V � 0 a � b � R O R A i Q c v ,� � © n o 1 C 1 o7..�....�� i ' o � r> � 3 H o z 1+1 H �u m Ito. 7- � A —Li FEE %�- COMMONWEALTH OF MASSACHUSETTS Board of Health, MA. APPLICATION LOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - O Complete System ❑ Individual Components Location 2 N4,�T/�i ��� � Owner's Name /<-� U91"YO e Map/Parcel# C) ._ !`� Address Z6 Ave gT z l Lot# Telephone# Installer's Name)rC'gU.477d&) Designer's Name z x/ ca- Address /s �tJ�lL /L�S�tJ 1V4. �ARWLC% Address ��/ �OX 98� �4,Ur)W,C�i t�r� Telephone# S � 7- 47- 7 ; 7 V Telephone# Type of Building �(,tiF_ZZ/x7� Lot Size sq. ft. Dwelling - No. of Bedrooms �J E 0 2 C0 rri Garbage grinder ( ) Other - Type of Building Other Fixtures No, of persons Showers ( ), Cafeteria ( ) Design Flow (Mill. req �L.uired) p ' � d gpd Calctilated design flow � y 4 Design flow provided �3 O gpd Plan: Date 73 " 'Y ^ Ntnnber of sheets Revision Date Title S OT Description of Soil(s) Soil Evaluator Form No. CSz // / 1Name of Soil Evaluator � QO?C-ii A4t /-Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS % �'L7 4 ,7 L %A'U 9 lt—< GU / -r-44 <'TiJ Ai G The and�{ igned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agisees to place - J ra ' until a Certificate of Compliance has been issued by the Board of Health. Signed ✓ Date.._ — Inspections K ao, 1 COMMONWLALTLI OF MASSACHUSETTS Board of Health., ���a'1n NIA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System FE1 � tt The undersi�l heyEttyy,, cerl�fy that theSewage Disposal System; Consu-ucted (}.Repaired ( ). Upgraded ( ), Abandoned ( ) b } �r dO ff �'/ C,44 T i43,tJ C- at 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-) �/- r, I, , , dated `I N , . Approved Design Flow �; -; j (gpd) Installer Lli k is _I Designer �? �_`� _i r, L Inspector:-afa4 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. Z-- FEE 1 COMMONWV ALTI[ OF MASSACHUSETTS Board c f Health, MA. DISPOSAL SYSTrM, :ONSTRUCTION PERMIT Permission is hereby granted to; Construct�/j Repair( ) Upgrade( ) Abandon( ) an Indi6dual sewage disposal system at Z�? IU©1"7111 /- 0'• ZOO 5 %- Y,,W, I " 'ZT/ -I as described in the application for Disposal System Construction Permit No. - `/ dated, Provided: Construction shall be completed within three years of the date of th4ermit. All local conditions must be met. Form 1255 Rev 5196 AN Sulkio Co. Chark� w%MA a Date �___ Board of Health o ¢-� �a0 =ti o N O` u � , s C � r o t" � M o a 7, z IV N 9 56, �� z cr x y � � H N J Q ro O A � Ic- I 1 N n a nrn C rn M. M. z n z A z C) c 7- 0 z Cl p n W" °° ro v, ro R ro ro n C?7 n a M CD p on, cD a A: o =1 o t o roCD ^� 0 n 1'rf k co 4 t G) (D ro ro =s 02 = p n'n, m-< rA 0 CD e-r � cC CD- (D o� � y 03 o r~ w A- 0 rDD DR EA EOD _ ro ID N 'p G �•w �w'' `z (D�. mv V) tz C n m p O nCA R> o, � a' F Lri CA ^ x ono W CL��� rm cD m o n ro cn z C co CL rt CT ro p ? (D = cn a S Niy cc)�< w i„ ch o_ cD -C o CA (A r• y� CD �o tn�J41 m m � � p -� O O =r rD ro W 0 �: S 11� ro oQll (DO m m (D �. cD W N / N 0 Q v e G C Qf Y1 A W N F+ K � w d ^ C h a m � LU r 0' 3- Ir 3 a 00 A r a �o fn A R cu 7 m N w S T � T A 1 v r1 I LA w �%6- f r IA 'i -O� z M m O C G7 r $ mrn 6 n.. A z � c� (7 a 0 dC, I!1 0 O 7C y .. Q Q yW��~ MM - I \` rmv *i# NJ L 0• \ \ j \ O 9 / / O) G 0 / O rn M� jN> O p D n O WC) ` bo m OD �iC' /0 ` o JC 4� _ ' r Ao o O C� mw y F 1+ µ ry 9 0 O 986' o D E t Fn DN eor�o"• $ r0 �! N � `< m pD w rn m i'� to ; D a D= D a`°o� �e �p �} �� O A Z. Z b aX Z �~~ c �N Z �� �Z�N�O oS O � i t t.'�5 O m D O C7 0 -{ N 0 N F �co o - x O o o.n c >� cf) O c,, D Co h '�A U) M a° = O K: S cD C4 s O D N ► J Q �O Z r 4b o �r h N �s aye D Dr "' Z o cn 3 J W o