HomeMy WebLinkAboutApp-Permit-ComplianceNo. }FDGI�^ CI'b5� -3 ' FEE 3 SOV
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COMMONWEALTH Of MASSACHUSETTS _rRE"t-k 4
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Board rfHealth, 1 LTi MA. R, 1;;lVF'
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION EMMTJ WOO
Application fora Permit to Construct( Repair Upgrade( Abandon( - 0 Complete System D Ie dividt9 ,�,CQjippXett -_... 1
Location 2.45A-efAtIC-_
Owner's Name Z(j•sLPI{
Map/Parcel# CJG (
Address IEr C 'T O. • CuiT ' ✓
Lot#
Telephone#
Installer'sNameC
Designer's Name Tc
Address IS(�1� .-_
T /., l��
Addressxa54Qgd CGJ (..' �✓ C t')
Telephone# ,� %-7`
Telephone# tg '
Type of Building - d at'7t-%T't 4-(__ Lot Size ( k 9 y 9 i : sq. ft.
Dwelling -No.of Bedrooms 3 Garbage grinder Q,O
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other F1XLUrCS
Design Flow (mitt required) 33c-1 gpd Calculated design flow
Plan: Date C1- A5 -.-i Of Q° Number of sheets (—
Title _a __ -T . CW<t �C= �
Description of Soil(s) _
Soil Evaluator Form No
Name of Soil Evaluator
Design flow provided .349, gpd
Revision Date
of Evaluation 9 -10 -;to( T
10
DESCRIPTION OF REPAIRS OR ALTERATIONS .3��15'-r39(_t_, 6.t �l.e ' M::4i
L73 Alr�ai %!-�v tl-�ivK 773 C �oc� C— ra ou H -,to GE4md; " r.e�jt
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to plac �die system in operation until a Certificate of Compliance has been issued by the Board of health.
Signed �\\`�-v�'`— \.,_..� �.'-_'._ Date `7
Inspections
No. b"C-1G-6G�58
C®MMONMTALTII OF MASSACHUSETTS
Board qf7-lealth, f A-P_A ^9C1(: RMA.
CERTIFICATE OF COMPLIANCE
FEE ZZ_.C.V
6 ola�'b�
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned herl, certify that the Sewage Disposal System; Constructed ( ), Repaired ( , Upgraded)( yAbandoned ( )
by; 01AP?r 8 b1i= P& r d f 5 %C2 c c`) d
at`+-1.8.^;'6f..7'd'
has been installed in accordance with the provtsi ns„of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. ) c(-. ,,PP" `� 9 ,dated ik,3 ��"-,{ of 5 .Approved Design Flow '3`1 e (gpd)
Installer r�;•d..ex li f..f_s:* ,E"8"' % P'ytip' ttc' w
Designer:U�,Z,lybAtl)Ciflf�L�, Inspector: , •4Q, , e-j4j Date:-AOA'Mv"�' r
The issuance of this permit shall not be construed as a guarantee that the system will
function as designed.
No. ' ci %{ �.,! G ^. (c1'.� (:� e' t / .-;.p (r'`C:i,v { �) �.° rim^ {`,J 1 C;: Z�tl t )i & IS/
S/,-13 4NxG.,- FEE
COMMONWEALTH OF MASSACHUSETTS c��*- 1"7-71
BoardofHealth, y°Cj" i11Q( r+r - MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissionisryherebygrantedto; Construct( ) Repair( ) Upgrade��✓}�) Abandon( ) an individual sewage disposal system
at � "^8 / s d or--- ��"�'s�°et" _- t �/``••"^ as described in the application for
Disposal System Construction Permit No. I"' ` dated 8 o
,,11
Provided: Construction shall be completed within three years of the date of this permit. All oval conditions Hurst be met.
Form 1255 Rev. 5196 A.M. SUlkin Co. CludeslavghUl Date Board of Health fit L-"/., r•'`"µx