HomeMy WebLinkAboutApp-Permit-ComplianceNo.bo PC -t9-6937 &P l �i`9rlic> % sSoo
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/%7 -COMMONWEALTH '�O/F7�I SSCUSETTS c. 115G�rS�
Board of Health,/MA.
APPLICATION FOR DISPOSAL SYSTEM CON TRUCTION PERMIT
Application for a Permit to Construct.( ) Repair( ) Upgrade(,'AbandonO -C Complete System Q Individual Components
Location 169 W06J
P
Owner's Name.,( t) Y-0 0 ICV 111'
Map/Parcel# bo
Address /69 W054 i f -k Via m tA-rL
Lot4f
Telephone# Soo - 1W ' ,3 r
Installer's Name Lv i�(i, I�
Designer's Name
Address 5 D (kIlq 1 ^�
Address d63 , etu&v
aha x 3 .'aufti�
Telephone# " i�/
Telephone# �5
Type of Building Lot Size sq. ft.
Dwelling -No.of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Osier Fixtures
Design Clow (min, required) gpd Calculated design flow ?J Design flow provided L:F gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONSyCipf-v—
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to not t{o1 �agce disystem i operafion until a Certificate of om 1'ance has been issued by the Board of Health.
Signed i r tnil(i Date
Inspections
No p`„"r,`'e,i0.1 v t tl ... (r" ��",t..�.;,` Ct4
v COMMONWEALTH OF MASSACHUSETTStA
Board ofHeadEle, k-L-� Art( MA. by—
CERTIFICATE �4
OF COIF PLIANCF
Description of Work: ❑ Individual Component(s) ZI,Complete System '
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded'(,,,+J, Abandoned ( )
by: 1l tr (I ^-t /1to r{ (t C ) b r`.5 -t1:1 a,J_. .
at )I- I','^(„I C -f
has been installed irl.accordance with the rovisjons of r$10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application tNo. x” '' ``m 'i dated �"r` a1'" ” t` r-� . Approved Design Flow 11 (gpd)
Installer (I t' ' i {m, ( t l.,t �(, r� t 4-_.. "i .m t (`°�f^ t i" { (tL�
Designer: `gIi ;r`i` cLr tri6' t wL Inspector: s'lit, 7%n A-1 -,~f Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No V-,4'10 V," .> FCS
COMMO FALT�f10E MASSACHUSETTS
Board t f Health, V -f? mo t,} -n -i MA.
DISPOSAL SYST-1M CONSTRUCTION RFRMIT
Permission is hereby gran ted to; Construct( ) Repair( ) Upgrade(,,)"Abandon( )an individual sewage disposal system
at 11 • '; A,t) f /i as described in the application for
Disposal System Construction Permit No. ;r , dated -"2 s
Provided: Construction shall be completed within three yells of the date of this permit. All local conditions must be met.
Form 1255Rev. 5196 A.M. 6ulkin Co. ChaEeslaen, MA Date,,- ''• Board of Health