HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6G#m-17-3 1580
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COMMONWEALTH OF MASSACHUSETTS
FEE
Board of Health,� , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( andonO - 0 Complete Syste Individual Components
Location ;L59 Now E-( MAto isr
Owner's Name 50ttU LQ&j
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Map/Parcel# KA? -C:D (j® •.- It 45
Address KA ST
Sa , l�/
A k
Lot#
Telephone#
Installer's Name CA -P (DL C:r PT 1$6
Designer's Name 0C=te.1 e&UtV ,6r tdpet
Toc-
Address 153 QVog
Address (gL W.CZOZ4:-i GLO
'F'opepr
Telephone# 501§ -4-1-7-28-2-7
Telephone# 5a 9 -4'171 - S l
Type of Building IZES�CN e �rL Lot Size I eZ C04�nq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 33D gpd Calculated design flow Design flow provided 342,7 gpd
Plait: Date 44 q -,;L o r1 Number of sheets .2. Revision Date
Title 25Z W oy I t ,MAA Q ST
Description of Soil (s) fv ,G LURA SA i0b q5ik 3X" /56s, ?%AK!r
Soil Evaluator Form No. Name of Soil Evaluator P, C'( 0 M� Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS V 54E GX4 r*ASy t l OIt7® +�C.C��.•l ���I[C. � [�.
- May H - to n _0Q -r-o 00 500 c 5&"&j ca - ( 0 waw" au'<�Ir r,64AA14(w-s
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.
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Signed 1 , . �� 4____/ Date 14' i 1' xot'1
' 1 a
Inspections.
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MASSACHt
COMMONWEALTH C�ao%vi "O-30cl
BoardofHealth, �/1 MA. 0
CERTIFICATE OF COMPLIANCE 1>6°K i
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Description of Work: Gol(ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedbandoned ( )
by: A1r=(A)t1Dr= I �aQ�S�»P
at A52 NOWT ( P -o r� i ►.) - T°6 t� /� j tf 46'AMi.OLIVI't
has been installed in accpr4ance with the provis ons of 310 CMR 15.QQ (Title 5) and t a roved design plans/as-built'plans relating to
application No. dated 4, Approved Design Flow 6y8. (gpd)
Installer its l l Yiir-- �'�) �d�L 1G�s _2 I CAA iX&k._) t",C`a PEMX`a - __---
Designer: ({.hill iC,� (.�Gj,�nspector: e Date:
_ "/ '
The issuance of this permit shall not be construed as a guarant that the system will function as designed. .
No. GnthQc k -7-3 i tl O' CA REV131 �) eG FEE^ 60
7 I � COMMONWEALTH EALTH ®f MASSACHUSETTS "��30 `
/ Board of Health, �Y, o- (_U74 MA..
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (6,J.o'Abandon( ) an individual sewage disposal system
at 052 &L+(2RMA A+tmk) S -r :50QT&,( YA]2%6*(00-MA as described in the application for
Disposal System Construction Permit Nol�, dated/� I-1.
Provided: Construction shall be completed within awo�b he e�d of this permi . All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Datel:,_� Board of Health se 117(�r