HomeMy WebLinkAboutApp-Permit-ComplianceNo. C�.R-3 N g anE-lq -- 0 0 6 8 G5' FEE .06
COMMONWEALTH OF MASSACHUSETTS 0.3 o
Board (f Health, y41213W )TF4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRICTION PERMIT
Application for a Permit to Consn'net( ) Rcpair(y) Upgrade( ) Abandon( ) - 60 Complete System ❑ Individual Components
Location
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eG--J ITU ''L
Owner's Name - —
Map/Parcel#
Z Z
%
Address
Lot#
2,-7
1 28
Telephone#
Installer's Name 7b,-
All 6
Designer's Name ti/i.07i v -
Address
Axn (0(.i
� S�W tic,
Address 6 o K e ?+ t C J t4� d
Telephonc#
C
0 ��- 'Z jOO
I Telephone# 5yg' 3(00 33 ((
Type of Building t"---c-S ( Lot Size 0 -ll Ae-f sq.ft.
Dwelling -No. of Bedrooms Garbage grinder ( )
Oilier -Type of Building 'f t R5. f. --e- 6 m - No. of persons Showers ( ), Cafeteria ( )
ocher Fixtures
Design Flow (ruin. required) 33C3 gpd Calculated design flow 3 5b Design flow provided 3.50 gpd
Plan: Date c'i- cl I cl Number of sheets _ Z Revision Date V'\04 -0 -
Title 04A
Title
Description of Soils) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation H-2-9
DESCRIPTION OF REPAIRS OR ALTERATIONS 4 o(AC-e +--et t [ZCK CZSSf)a"0" S -e -e- P(/+ -I
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees teration until a Certificate of Compliance has been issued by the Board of Health.
Signed— y t to pla thyste n m opd
Date (' 3--( t
No. ll(i (,f �41, "rii FEE
r , .
COMMONWEALTH LTH OF MASSACHUSETTS r 1
Board of Health, XA9MOtAll- , MA.
CERTIFICATE OF COMPPANCE
Description of Work: ❑ Individual Component(s) t Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (br), Upgraded O, Abandoned ( ).
has been installed inraccorFlance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No `e'''--y�°�,�, dated 4 -- iyt' rte: Approved Design Flow -ti ti ate) (gpd)
Installer ('_Jr sft +i' <.a ltl s
Designer: V-4, -f C ,- Inspector: s ,r ``� '-i?,�... t Date:
. 1
The issuance of this permit shall not be construed as a guarantee t(tat the system will function as designed.
No t,:s°!(t iri i P '»:'✓C,l 'h � r ': FEE 111 3-11 t?0
COMMONWEALTH Of MASSACHUSETTS
Board of Health, A"s-°� "1 0Va} ,MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair6!) Upgrade( ) Abandon( ) an individual sewage disposal system
at �- (� c' "� ,tl r ,�"7 /), c..,'._._ as described in the application for
Disposal System Construction Permit No.'2,P� , dated,` -
Provided: Construction shall be completed within three years of the date of this permit. All local condidgns must be met.
Form 1255 Rev. 5196 AM, Solkin Co. Chedulan,MSA Date G'111""'�'/` Board of Health "` "i / '� '"'�' - `1=%'