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HomeMy WebLinkAboutDisposal System Application/Documents_n - g F-r F- Fr F U r� OS .a o, a 2- v s2 � n N CP 09, c C b J- r R a. h h { O v rt A "1 .^ ry r ro eb T O N y z � -�( " N o .9 L Ws00 W p d Gas � • S � 3; o y '6 z n� �1 S � 1 o n ( ) H � h C pi CAS ❑ � III fTTT' n � H a b 0 m No. COMMONWEALTH OF MASSACHUSETTS Board of Health, , MA. FEE 5 � + APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) RepairO} Upgrade( ) Abandon( ) - ❑ Complete System I Individual Components Location `$�oR�c�� oo,& Owner's Name Map/Parcel# 2 A 1 1 S o Address Lot# Telephone# 2 p 3 • �� . ZCp {p Installer's Name 6116 Designer's Name �phtS 4 C�nV���Mcnr�� Address 3+-1 (�OV+L 1130 SOoow.o'-' Address �O &x 331 Cer�.�Y. Mo. 020S Telephone# ; �b - (� ��5 4 Telephone# -•-1 y • - ` �(o Type of Building N S avJ0' ';,,,. Lot Size n SIC) -- .. sq. ft. Dwelling - No. of Bedrooms tyzd c a m rA L Garbage grinder( ) Ogler - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided - gpd Plan: Date 01 44 2, Number of sheets _ Revision Date Title Description ofSoil (s) Soil Evaluator Form No. Name of Soil Evaluator 1° lAtf i Date of Evaluation 01q DESCRIPTION OF REPAIRS OR ALTERATIONS a r��Ci 1 n 0 t {i'ho n')e �UO Ga 1000 ac4W n Cl' to ka'tL. J The undersignedbgrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agroes�t) not taphce the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ti" _ Date ti Inspections No. _ COMMONWEALTLI OF MASSACHUSETTS 1 � ' I `t �1l FEE � S Board of Health, MA. CERTIFICATE OF COMPLIANCE Description of Work: ® Individual Component(s) O Complete System The unfddersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (,), Upgraded ( ), Abandoned ( ) by: 1s1 V [ ".1c+- n ". at I?or>& 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. •.)' /: 1 ;, `I dated / I "7 j Approved Design Flow (gpd) Installer i—XeG'UGrt . Designer: �� C� e(� y �.n 1 c me�<<, Inspector: _f h .i' �Inh D. 1.i Date: - IQ The issuance of this pewit shall not be construed as a guarantee that the system" function as designed. FEE J COMMONWEALT14 OF MASSAC14USETTS Board of Health, -1 aI rNQA. , MA DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at _- ` ; , , ,, , _ as described in the application for Disposal System Construction Permit No. _i�/ /fit/ , dated Provided: Construction shall be completed within trace 4*&r9-bf the date ofoxis �rmit. All local conditions must be met. Form 1255 Rev 5/% AM SulklnCo. ChxWowe,MA Date A, Board of Health n -MW �• J -j O� w� p� �f O n A a' � w O� �• n< O O. C 0 Coo O� y O (� `Cy �• (D O� n~ CD 00 (40cr G O iD p' LA O sp a O O n W O Z'D T a � a �. �a•�� C N m n•h f�9 � v�i v l fR' �• ,w�+ A W R O fD O O a c) c w R Cl- CD w m R a r� �O O � 5 y oN g r n �. V ram`` � C O rOi, ti O l> `O 7d �ryp O co Z m w n m 'C C cr. 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