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HomeMy WebLinkAboutDisposal System Application/Documents�d J O z J N Ld 0 r� c y a 0 � vV LA too No t' -)(x�t1 FEE 1� COMMONWEALTH OF MASSACHUSETTS Board of Health, , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair; ) Upgrade( ) Abandon( ) - ®.Complete System ❑ Individual Components Location,:,) ?., CC.. d-1 e Owner's Name r — Map/Parcel# 1 Z — LA\W Addres CC..f11 I P Lot# Installer's Name �" -`s t eA fi -� Address P a G -v 'Telephone# ( Designer's Named �� " U�G(Y'7 Address, 1 c_ VcN Telephone# r ` Telephone# Type of Building _ ce -, t Xe ._ Dwelling - No. of Bedrooms 2 Other - Type of Building Othei Fixtures Lot Size \ sq. ft. Garbage grinder( ) No, of persons Showers ( ), Cafeteria Flow n Desi min. required) g ( ` q ) �Q_ gpd Calculated design flow )L Design flow provided ',2>3 .(2) gpd Plan: Date Number of sheets Revision Date Title Description Soil Evaluator rorm ivo. r DESCRIPTION OF REPAIRS OR ALTERATIONS VA 0 rk,-'Ai ,� r- S �'L..-- U Name of Soil Evaluator Date of Evaluation _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 � 1 , 1 1 Inspections COMMONWEALTH OF MASSACHUSETTS FEE � �-�- Board of Health, �1 _ MA, Gt CERTIFICATE OF COMPLIANCE l Description of Work: © Individual Component(s) P Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( } at has been installed in accordance with the provisions of 3I0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. ; • Qtl dated Approved Design Flow (gpd) Installer �Cn Designer: r �1, oo, n� (. )r,; t 'y -- Inspector, r Date:77 t The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. _bk2� COMMONWEALTH OF MASSACHUSETTS Board of Health, _�� n V - '\ 11 MA, DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE_ Permission is hereby granted to; Construct( ) Repair( ) Upgrade( +Abandon( ) an individual sewage disposal system, at r < _ as described in the application for Disposal System Construction Permit No. 5 dated 1/ 1J11 1, Provided: Construction shall be completed within three years of the date of this peratit. All local conditions must be met. Form 1255 ASV.5/% AM Sulkm Co CraiWowa,MA Date Board of Health —i- d CD CD rD Q 0. S w w J CS w to w w w l? w N w w --• C N �O N 00 N �l N I" vi tv A N W N N N N O . . r! . ^ . -: W N — O . . . . . W N --• np-*�--1xmmcm<cn�m� �3cnzcnrncn�-vtoc-C I<~l< -�rrrcnpd�-n�p� CD O : O O C Cp •7 Cl) ^, C Ln C) h3 .7_ • .�•. O 0 ig .hr O .y+ a d yl< N .yi WOOMCDO 0 0 0 to CD n n. X 7 a. O O • I.tO O " C) -'. 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