HomeMy WebLinkAboutApp-Permit-ComplianceFEE J65�
COMMONWEALTH OF MASSACHUSETTS
El-elvrral(®` ),� BoardtfHealth, W.
l 0 12 2019
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION m M
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System O Indivi nal -Components- ""'• "`
Location
Owner's Namc MA &C_ 6G �v yr
Map/Parcel#
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Address jtg, I7 tJ ,� — '7. )' pa
Lot#
Telephone#
Installer's Name GO PCO1. S & g' _- y dc')
Designer's Name r �T'
Address
�cS•zrl}'E
Address
Telephone#
5ey -4.72 —e&< Z 7Telephone#
,j fj}� -3
Type of Building KeE:S� 144= Zlfi-L, Lotsize.— jD� l0 q..s -rsq. ft.
Dwelling -No. of Bedrooms 4 Garbage grinder ( )
Other -Type of Building No. of persons Showers O, Cafeteria ( )
Other -Fixtures
Design Plow (min. required) gpd Calculated design flow Design flow provided /1 W gpd
Flan: Date cr" (>" Number of sheets Revision Date 7 -/`/ -/�f,7 S$ -C - (�
Title ..SbCj,-, -f
Description ofSoil (s) fjg p :15WIZ0 (f.J :2_tl./
Soil Evaluator Form No. Name of Soil )valuator C. r_ 4=z A42; Date of Evaluation
DESCRIPTIONOFREPAIR.SORAITLRATIONS 1-1-10 j5 r�/!o<� "• o`''�'t .:> ?" �/�
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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 to place the system m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections 'a 4ryt U�
Nqs - &"aw4, egra COMMONWEALTH OF MASSACHUSETTS CCl
Board of7-lealth,� 11 `i4N EV14— Am.
CERTIFICATE OF COMPLIANCE
Description of Work: Q Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Dis'p'osal System; Colisn-ucted ( ), Repaired ( ),Upgraded( ),Abandoned( )
by: Cf� J&QZ,7 l62t`-�4:v'Y 1� -4r/&
at
has been installed in accordance with the provisigns" of 310 CMR 15.00 (Tide'5) and the approved,design plans/as-built plans relating to
application No i ' ° ^ l- 3 , dated.r d 2 t . Approved Design F16w `A m! (gpd)
,
9 I t7 � -, a- a
Installer �,r��
Designer t5.�arm *,vr r"-rP'. r:m: a.�✓^
;The issuance of this permit shall not be cons
Date:
that the system will function as designed.
No. ,"idti.7l§ 4 '" i Y -"� l 6 � �:�1"§'��`"l dl 1 0 r � w `.i .li���?.. ("t (1.{ �'F ``_i "r �� q�;'P (� �%, FrC
9
COMMONWEALTH Of MASSACHUSETTS' (A
Board of Health, F tri: Mil.
DISPOSAL SYS Fid CONSTRUCTION PERMIT
Permission is herebygrantedto; Construct( ) Repair( Y) Upgrade( ) Abandon( ) an individual sewage disposal system
at ( as described in the application for
c
Disposal System Construction Permit No. 3 dated 2
Provided: Construction shall be completed within three years of the date of this perp it. All local conditions must be met.
ra
Form 1255 Rev. 6186 A.M. &ulkln Go. ChatleNavn,6N .Date`s^&� r(—j c . Board of Health'
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