HomeMy WebLinkAboutApp-Permit-Compliance4w -,"e 0
No. 73
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® MASSACHUSETTS EC
Board of Health, 6q:gM7Uri� , Mt �� 2019APPLICATION FO. DISPOSAL SYSTEM CONSTRUCTION �P� T HEALTH DEPT,
Application for a Permit to Construct( ) Repair( ) Upgrade andon( - ❑ Complete •Systern-Ja individual Components
Location 4 .e &
Owner's Name h h
Map/Parcel# g
Address / �� fi/ [ (/v /� c� • .
Lot# ty tl
Telephone# O 760 g
Installer's Name l Cam
Des'igner's Name -a 9 1 � f' P�
Address r
Address , O d5a14 / 16 3 • rQoe12;S4 mg
Telephone# S
Telephone#, 36 �j:- 9d 4J&
Type of Building�/� / Lot Size. sq, ft..
Dwelling- No. of Bedrooms Z ej
Garbage grinder (v
Other - Type of Building. .. No. of persons Showers ( )_, Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date 4`'' —,;2-.7 Number of sheets .
Design flow provided 3 %! gPd
Title JJ ,� kl-fVAla k_ oi�✓A%srkl�d _ 4S /y 01.4,41
Description of Soil(s) al
19 q
Soil Evaluator Form No. ame of Sail Evaltaator% //4 Date of Evaluation 6 r
DESCRIPTION OF REPAIRS.ORAITERATIONS
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 la. a the system in ope n until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
�,, ��
Inspections Aged
No: lw"'1 1, 7s�1E
COMMONWEALTH Of MASSACHUSETTS z
a
Desi•'iiii of Work:
The undersigned hex
by 1,:_I1
at
has been installed i
application No.
Installer 1 1
Board of Health; , MA. �i SII
CERTIFICATE OF COMPLIANCE 7 /-1 1
Ef Individual Component(s) ❑ Complete System r dX jam} e1""e
)y certify that the Sewage Disposal System; Constructed ( ), Repaired (t�, Upgraded ( ), Abandoned`
:'o an with the rmisions o 0 CMR 15.00 (Title 5) and the: n
proves esign plans/as-built plans relating to
dated "/ f Approved Design Flo �'� (pd)
Designer: r's �' 1 l.' gt' j.� �ipelL�cir? �% r 1� Date:
The issuance of this permit shall not be construed as a guaran a that the system will function as designed.
FEE' tgJC
T COMMONWEALTH
SETTS
�Of D A.
.Board of Health,
DISPOSAL SYSTEM CONSTRUCTION- PERMIT
r
Permission is hereby granted to;, Construct( ) Repair(L-l' Upgrade ( ) Abandon ( } an individual sewage disposal. system
at C5 aili I Ai" 1 ,f rs x as described iithe application for
Disposal System Construction Permit No. C%-&14 dated /
5�
Provided: Construction shall be completed within-tU e rr,.of the date of this Permit. All local co d.itions must be met.
Form 1255 Rev. 5196: A.M. Sulkin Co. Chadestown, MA Date7- Board of Health � '