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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6614DC-18-0089 1:EE �56-- o0 /C--1 ®l l�I�AXTTTTIT f)F CArTTUCl-TTC di, f ;lZ Board o fleallh, a i �f MA. APPLICATI©N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT �rY Appl4ication for a Permit to Construct( ) Repair( ) Upgrade(v) Abandon( - ❑ Complete System •'U Individual Components r� t t`� a cation '] , Pj(>-rV\axC1e- rd 00 a MA Owner's Name (Zickwr , /PI i�ru-r0 ap/Parcel# Address C;-1'�hornbC'.'tY Wir&eOonm MA ot# Telephone# -tstaller'sName L1 la- Cons4-fvcWOt) Designer's Name Q S C &rOuQ ddress 90 6ojt 1.4g S.(kmis MA- Address2LAA ra.Q-% OK4 n W.VCL0rVWJ41 AA Telephone# JCo16- LA,3a (635 Telephone# S05� -ig S-Clle1 Type of Building �—eS I (\(6"al Lot Size sq. ft. Dwelling - No. of Bedrooms 3 Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other FixtUres Design Flow (min. required) 37 O gpd Calculated design Row 3 3 Design flow provided3 3 O gpd Plan: Date 7 /� �1 $' Number of sheets Revision Date Title t Description of Soils) _/11P�jitltn �0. Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 'dL-SOU GCXI W11 W - The undersigned grecs to in�thc�lerna d Individual Sewage Disfi(7 System in accordance with the provisions of TITLE 5 and further agrees ton o lace tn�i i'a Certificate f li:mce has been issued by ftte Board of Health. Signed Date $I eN No.:`�, Pte, ) COMMONWEALTH OF MASSACHUSETTS' q t -7` � Board ofI-lealilt, 's ')no-Fli . ALA. CERTIFICATE OF COMPLIANCE Description of Work: 0-1fidividual Component(s) Cl Complete System 1,4v V, The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded (1;), Abandoned by; at h has been installed itt.,accot.da'dcc with the provisionls-of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to applicationNo. l,�i-' ''� ^ dated,?-- i° "('s . Approved Design Flow (gpd) Installer llesigner: Inspectow .'t` i hr<=` t a �'��'° Date: .^a"" F rs`S` i, . . <. The issuance of this permit shall not be construed as a guarantee that the system will function as designed. p No. °� �;>("> ('y"�.+a�t�a>(�:1C�"Cic�r�,j r•Ee E c.r Bo(��c-18 bo8q COMMONT ALT1I Or MASSACHUSETTS 14. Board offleallh, '%//A 4?, 0 4 A, NIA. DISPOSAL SST1'M 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. �' f , dated 1t f Provided: Construction shall be completed within three years of the date of this per iA All local conditions must be met. Form1266 flev.6/96 A.M. SUIkIn Co. ClutleetaxgMA, Date Board of Health 4`; l C r•4/