HomeMy WebLinkAboutApp-Permit-ComplianceV x 0/71y,No. Jb4i C—I�1-�v4Z� B�DTQ- lo- C0(6%�
- �. 3 3 COMMONWEALTH OF MASSACHUSETTS
Boardtfl-leallh,{C1,Y� YYIDU%�(1 MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION P "
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑
FEE
Colo
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2 a 2019
Location 5.5' Qwc}Cid
t_ Uwllt Rd• W• gref tnoo6l,
Owner's Name Qhortwld BoQr Cots
Map/Parcel# y'1 I y
Address
Lot#-
Telephone#
Installer's Name 6 (�
�Gnceawo.4io�
Designer's Name 0owe C. pa Q,n •
Address 14 Te�bcrr
Address ej39 MwSn Sl•• grrnoJhM oc4
Telephone# Sob• 4"1"7•
oue-S
Telephone#log• 3102. 145q
Type of BuildingyleCb aC40-( Lot Size 331 159 sq. ft. +/-
Dwelling -No. of Bedrooms J0 3 Garbage grinder (40
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (thin. required) t WU gpd Calculated design flow
Plan: Date i 1191 19 Number of sheets _
Title
Design flow provided S5 gpd
Revision Date 55;-rz -k r
Description of Soil(s) SRR Plan 5
Soil Evaluator form No. Name of Soil Evaluator Cro.la F, Date of Evaluation -71 to I IT
DESCRIPTION OF REPAIRS OR ALTERATIONS �iCP) net D - box and SAS
The undersigne9grees to install the above described Individual Sewage Disposal System in accordance' with the provisions of TITLE 5 and
further afire no a the system in operation until a Certificate of Com fiance
to has been issued by the Board of Health.
Signed Date S 27 I
Inspections
1aiF'f > : Olc..lo�I�ti15
No.� rCE
COMMONWEALTH OF MASSACHUSETTS¢'' BO's Z
Board a(l-lea7tlt, _ s, :lid-� C 3 t�" k�"�" , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Components) ❑ Complete System
The undersigned hereby certify that the Sege Disposal System; Constructed ( ), Repaired O, Upgraded �'
waAbandoned ( )
by l' 0 QXCF)ody\ 1)CA-1) FOC ,
ar �'`'-, (FSS "-(.• .^{ fi Gal= VP, i -L 1C: -1i V�A )
has been installed in accordao.ce with the prop ions of 310 CMR 15.00 (Tide 5) and.the�proved design plans/as-built plans relating to
application No. fr_.. to SS , dated dc'%7 I .Approved Design Flow,°a (gpd)
Installer
Designer: VKYJ.IQ .JVK; ir,<t,,y I tl 9 Inspector:,4 vee ,n",�'"�;tl tea: `..e..� ._. Date: /L//2,/-` L
-� v l
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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4° � F1:C
COMM, ONWEALTH OF MASSACHUSETTS � " 3 cd
DISPOSAL
�p
Boardof Health, � F \"*�/1" tZMO )M MA. �
DISPOSAL SYSTEMI CONSTRUCTIONPERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(�y) Abandon( ) an individual sewage disposal system
at j�iy U _(�) �/A LL- Gl 1 Rb � I as described in the application for
Disposal System Construction Permit No. -sx , dated
Provided: Construction shall be completed within three vears of the date oftbis rmit. All local conditions must be met.
CL.
Form 1255 Rev. 5/96 AN, saran Co. Chardon, MA Date (CJI✓f . 0 .
Board of Health d'�-°W