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HomeMy WebLinkAboutDisposal System Application/DocumentsiJ �o w .a ro y �1, O rL 0 D w 'n o z eDft et V z n c. c � � n99 � 9 E M ^s w n od-n a o �rA f� ft az C. 7 n n c� o a :3,. O N o »+ } r � .7 C ti s `G ry R n rc 0 Ql 4 r rI 4 i c rb s n z c C rD r ru z y rrb ro f � � c S N'. yN yy, - a y- i9 y s6t-Z7- a Y- � 5 Ile FEE 5'�;7oa o y � D 6 COMMONWEA1.11I OF MASSACIIUSETTS Board of Health, _YAt t MA, APPLICATION FOR DISPOSAL/SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ; Upgrade: Vf Abandon( ;; - omplete System O Individual Components Location �Q +Q >��Q Owner's Name ' I Map/Parcel# Address Lot# Telephone#`- IInstaller's Name Designer'sName C,� Address Address _ Telephone# .�.� Telephone# 6 T e of Building ��� J1C ss ft. � I.flt Size_�,� q, Dwelling - No, of Bedrooms ? + Garbage grinder( ) Others Type of Bruilding No. of persons Showers �/ p O, Cafeteria ( ) -�,Other\lFixtures D-csigi'�Mw (min. required) gpd Calculated design flow Design flow prodded _gpd Plan: hate Number of sheets l �r Revision Date Title Description ofSoil(s) Soil Evaluator Form i4 Name of Soil Evaluator Y�rC, ��� Date of Evaluation DESCRIPTION OF REPAIRS ORALTERATIONS„� `t G, � � � „� � \Y� \: � � "' .� � � � C �� � ~1��� ► 9` 7 v C] �r G� �--� . � rl� i�1.�.� ,``'�'�'''71C-'i l`� 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 in operation until. a Certificate of Compliance has been issued by the Board of Health. Signed �'^'�°`� Date G Inspections COMMONWEALTH OF MASSACHUSETTS �� t' Board of Health, �_� _ 11�q, /�S 0 ,� CERTIFICATE OF COMPLIANCE Description of Work: O Individual Component(s) u- 1tomplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded V", A•bandoned ( ) r— by: 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, j dated Y �' Approved Design Flow .) (gpd) Installer id Designer:�_L r�_�..5 Z :� r ,Inspector: Tr -� � i r � i + Z, rfData: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. COMMONWEALTH OF MASSACHUSETTS Board of Health, ,��r _ MA, DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE —_ Permission is hereby granted to; Construct( ) Repair( ) Upgrade(, -)• Abandon( ) an indixzdual sewage disposal system at _ {,' -#� J-�-� as described in the application for Disposal System Construction Permit No. -2- /- ?y6 dated Provided: Construction shall be completed within thrC&-*earwof the date of this permit. All local conditions mast be met. Form 1255 Rev 5M AM Sulkin Co CjWreslam, KA Date ' A Board of Health �?-_ b T a 1 6 Aj z C z m A z c. CCD W 00 CD a < :3T W w' O O O y � y rl CO O L O 91 H � O O c o m M n o y y � �� z rn D e co y < a w y y 9 C) C7 w O w O r3 R CD S o— afDi n, 3 0 El ::r O c m C y o Gi rt r. w O O O. O �- =r O tyRO c Cl. 0 CA o (D a Ln °C w �A O O c> (A 4 C su O c = voi � C (D ^G o y y rD O O rr n w rt 'I = rt =r rY r-r CD C. m CL A+ v 3 m z M rn �:. 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