HomeMy WebLinkAboutApp-Permit-Compliance.21
No. &p1?DC.-1 / 0 `� FEE t 66,00
COMMONWEALTH OF MASSACHUSETTS GSD !o Z
Board of Health, MA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 7 Cid-Ij5A:"
Owner's Name JA(46
DC -&J
Map/Parcel# AnAddress
371 mtv!
.A�Lz W.Y.
Lot#
Telephone#
Installer's Name C�a � � �
Designer's Name EAS
S oiL
Address 1,53 S -r HkS4p
Address Pct gq i,?
S*-rjqty N
Telephone#' O . 1, f '1 7 -
Telephone# j5e>2
00
Type of Building AJ0u'Ct//04 �L t»�Tl {� Lot Size ���� sq. ft.
T
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 440 gpd Calculated design flow Design flow provided 50gpd
Plait: Date I OL a-9 " 3..010 Number of sheets Revision Date
Title -113:71 „r%Zti7oTt r012 V W(&2 ,5T'
Description of Soils) co 519 SiE[)DCO2 60�,, /S
C, P,
Soil Evaluator Form No. Name of Soil Evaluator D 51Z {tea Date of Evaluation 1(- 30 -,Ao ( A
DESCRIPTION OF REPAIRS OR ALTERATIONS USS Ou6r,a tz -M lu cle_� ti oGc) C-*4LL0j
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3(Q L.umio 26QF L. <;5j2tx- 4 TN G I i.i G t rJ dl Nr� Go lJlt=l c?-2'cci�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no Iacethes�ystem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �� �S� / r Date I- 31-.1 g 1 -1
No.
C®MM®NW-EALT14®F MASSACHUSETTS oti 3
CCB ® 44
Beard of Health,JTV
MA.
CERTIFICATE Of COMPLIANCE
f )
4
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Ip, Upgraded ( ), Abandoned ( )
by:
at III Res "7:=- _-3_9 1114kIf� ST
has been installed in acco d ce with the provisions oL' 10 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. -� dated' f Approved Design Flow (gpd)
Installer OADGe,e,tt �G &wToweSES:� _R I CA CAPE -N
Designer: EAs—S-� X N C.. Inspector:V_XW IE&Irz Date:
The issuance of this permit shall not be construed as a gu itee that the system will function as designed.
,. No.�a Q �� t) 0 'i `.�' `lam S
i7
COMMONWEALTH Of MASSACHUSETTS
Board of Health, T m f)OA , AM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair (2Q Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
Disposal System Construction Permit No. �� dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this �t. l local conditions must be met.
Form 1255 Rev. 5/9/96 A.M. Sulkin Go. Chaadesslown, N,� r Dat �` 7 Board of Health
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