HomeMy WebLinkAboutApp-Permit-Compliancef �
No. &Wsr.-tq--0(025' 93l )TR-2o-ootolg
l 0, i ' COMMONWEALTH Of MASSACHUSETTS
Board (f Health, � a.r m 0IA+h , MA.
FEES
Cr- It: CF68
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Rcpair(✓f Upgrade( ) Abandon( ) - U/Complete System 0 Htdividual Components
Location (DI G&rrq
Owner's Namc R, O,arct Lue(e,r
Map/Parcel# '50 ZOq
Address (7_ fjc.rr AVG go.rrnookh
Lot# t
Telephone#
Installer's Name 6$ (j rGX CAJ 4�.on
Designer's Name to -7co1i
Address (y-Tembcrr Ln. (=orts4rdat4-
Address 155 (neo 1�46tr Rd S. GhoArh-Awt
Telephone# ,rj'ois•q-1-1.0(0S3
Telephone# 506.3(04. OT?gq
Type of Building J�os;dtn
Dwelling - No. of Bedrooms
Oilier -Type of Building _
Other Fixtures
Design Flow (min. required) 2Z 0 gpd Calculated design flow
Plan: Date V7. 201q Number of sheets 1
Title
No. of persons
Lot Size 17, 070 sq. ft. +/
Garbage grinder (14o
Showers ( ), Cafeteria ( )
Design flow provided 330 gpd
Revision Date ri -x,?—tq
Description ofSoil (s) See plan
Soil Evaluator Form No. L4 Name of Soil Evaluator noatd Cot ono%o Date of Lvaluation 70_.?A• 19
c
DESCRIPTION OF REPAIRS
The undersigned a es to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree of to lage e system in operation until a Certificate of Com fiance has been issued by the Board of Health.
Signed % Date 27
No. p ¢i m""9 Cj-- -+ ._-. °`° m.(ry FEE
U
COMMONWEALTH OF MASSACHUSETTS � � �)�
Boardoft-lealtb, yr^f":, �f f" MA.
CERTIFICATE OF COMPLIANCE oK
Description of Work: ❑ Individual Components),CoYiiplete System
The undersigned hereby ccrt4 that the Sewage Disposal System; Constructed ( ), Repaired (,-Yl.lpgraded ( ), Abandoned O
by.
at G ,, irk „a „� fr.. .
has been installed in accmdanci5'with the r vis. ns of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No i(' �� 4 f �,�' ,dated tee: P"'?' .Approved Design Flow _ m rD° (gpd)
p -,
Installer 'ta "t "$"" 1..") r (>{ �+""-'r? ""=i.1.».r 14_____ a
Designer:. G^.'° .""" k C` �#.- o"� Inspector: ll .�c„ .�3a°C `anp':r,..,,+'® Date:
The issuance of this permit shall not be construed as a guarantee drat the system will function as designed.
No. !ere-aV°p ��'p""(.,}n �.%;.� ,,>.� 8:.:="!..�'i Vrt V 8�%I`»•t
y- �' d COMMONWEALTH OF MASSAC14USETTS
a�
Board of Health, A t t ) MA.
DISP05AL SYSTfi.k CONSTRUCTION PERMIT
a
FEE
!p r'+
d iF 9 9016.....
Permission is hereby grt (rted to; Construct(a ).,••Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at a �°°^. �.aC. '+�c°'`•a a � l
as described in the application for
r
Disposal System Construction P'6jjliiit Noj6 "dam, dated t,
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form tzssRev. s(sea.m.ssitinGo. chenesimtn,tuDater'"/sst`e»n' Board of Health