HomeMy WebLinkAboutApp-Permit-ComplianceF LbTFP� - 2Z - 00( 301
COMMONWEALTH EALTH OF MASSACHUSETTS
BoardtfHeallly �ii`n_/VI(,�(,1f�-i• ,MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ 1
0 9 2019
HE_cLTH DE=PT
Location Aq 00/m
Owncr'sName vi I"iaf tfaf9C,Q.G1
Map/Parcel# 3i J`�`J
�y/
Address '�1-f t fi - o tO I�-btt W • IGtr(ll Uw t�/
,
Lot#
Telephone4k
Installer's Name het' Q 6utd '+Iudc&t,,�—
Designer's Name lof) e
Address at
Address q,39 p,th z6f�. krrueU.'l�t
Telephone# k 9� - 94 ((0
Telephone# sD -,9&g • e.&41
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (//omyit . rcgt iced) 0 gpd Calculated design flow
Plum Date G� �- r(• Number of sheets_
Title
Description ofSoil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS ORAITERATIONS
Lot Size ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre o not to cc
th system, in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 7 I tl)'�C,V7 I r� Date �P
Inspections /7S �// f Gi Oji I S t�
No. e'`lioI �ii� 1` 9-Qt.,"«t d �1 �I FCL
COMMONWEALTH OF MASSACHUSETTS
� � a �� Board ofl� tt �) � C t )"3! MA. ��9
t CERTIFICATE OF COMPLIANCE R04
Description of Work: l] Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired O, Upgraded,(}, Abandoned ( )
,,
by:
at -`d)o f((lt
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 1 `! " >k. =�' ,dated <:''f�7 i`/�"r�' .Approved Design Flow S -i 6 (gpd)
Installer z}li{tr 4 ;qly J
g �r
Designer:. Vt A 1 ! 1 0:, F _i! fi l life f i i 6 i , Inspector: a • t. �, r i z� T a ^a^"" Date: ^`,8 n+ o-+ ' ar"
� a
The issuance of this permit shall not be construed as a guarantee that die system will function m designed.
No. P'o"`i 1,"x",- c)f:::'7 `m../ i„ �r' ;�`"",aqu" "� % 1t;�°:p7 <. ` °"t-ts ) ...-.., FEE()tJ-
CO]�MONWRALTH O MASSACHUSETTS <�� I1�' 5
a d ^c cr i A fst1QQT1+ MA.
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
I'
Permission is hereby ranted to; Construct( ) Repair( ) Upgrade �j Abandon( ) an individual sewage disposal system
i t
at Fi(� f'Kl 1 5 - as described in the application for
Disposal System Construction Permit No. Jt"t ' tl Ca , dated �� r,� t/
Provided: Construction shall be completed within three years of the date of this permit. All local conditions rust be met.
r'
Form 1265 Rev. 5196 A.M. SulkIn Co. Chadeslam, kN Date ' / Board of Health