HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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/V,FEE, A
COMMONWEALTH Of MASSACHUSET cll�c6�3
Board of Health, ,. IY160D , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PER ITMAR 29 2019
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon,( ) ❑ Complete System O individ al c94DEPT.
Locatione: 11
C. e�
_ Owner's Name U i A,4 -ON
Map/Parcel; ex
r
Address ,
Lot#
Telephone# U7 _ _&?
Installer's Name1,
4c
Designer's' Name
Address
Address
Telephone#
_ /
Telephone#k
Type -of Building 14, 5.1 Lot Size sq. ft.
Dwelling- No. of Bedrooms Z_ Garbage grinder ( )
Other -Type of Building _ . No. of persons Showers ( );, Cafeteria.
Other Fixtures
Design Flow (min. required)
Pian: Date.
Title
gpd Calculated design flow
Number of sheets
Design flow provided gpd
Revision Date
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS:: OR ALTERATIONS ����'°� � ��� SA %tom, 16X j
The undersigned agr s to install th abov described Individual Sewage Disposal System in accordance with the provisions: of TITLE 5 and;
further agre n to lace t to in operation until a Certificate of omp 'orrice has been issued by the .Board of Health.
Signed �� Date Z
Inspections
No.��'iC'f FE1 W
COMMONWEALT14 Of MASSACHUSETTS av
Board of Health, o(mri , MA. 0 ( V V
CERTIFICATE OF COMPLIANCE 1
Description of Work; Individual Component(s) ❑Complete System.
The undersigned hereby certify. giat the Sewage Disposal System, Constructed ( ), Repaired upgraded ( ), Abandoned
by eA ,ems ) A,' /X.
at 0 ( /17 r Q S�
has been installed i} accordance with the provisions of 10 CMR .15.00 (Title 5) and the approved design plans/as-built plans relating to.
application No. // , dated d " _41 . Approved Design Flow -- (gpd)
Installer 4,fQ,✓l.'4( L :�1, tle LC •G J CCf�(�C �-U,....
Designer: Inspector: �✓ / Date:
The issuance of this, permit shall not be construed as a gua antee that the system will function as designed.
No., $0Cfl�^L�.-�J`7 �i(J►�1.. Ctjt-�,SrP_) FEE
COMMONWEALTH Of MASSACHUSETTS (�33
Board of Health, VA9MOUT74 , MA.
DISPOSAL; SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby gran ted to.; Construct( ) Repair{,/) Upgrade( ) Abandon( } an individual sewage disposal system
at . cZ 9 � e �P� �7 . as described in the application for
Disposal System Construction Permit No./?— 0 ,dated'" ,2
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
"�` J
Firm 1255 Rev. 5196. A.M. SWkin Co. Chatlestown, MA Dat Board of Health / �'