HomeMy WebLinkAboutApp-Permit-ComplianceNo.ol-l- c -t9-10-78 0L0,TP-- ZO--00-,) 6W
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, Ya rm a'Ji , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair(, ) Upgradep( Abandon( ) - dEkComplete System ❑
PCE W 63 0 V
23 2019
Location e av)qel(
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Owncr's Name 1Gt'.n ne f --}A �>Oh¢
Map/Parcel# 2 - 1 1
Address 4c> (2-u 2c' HA
Lot# t{5'
Telephone# 8 Z.4 S -s
Installer's Namet�
Desig ner's Name
Address 1 �Zabe c r a rr r esl-clwi v
Address 12 W, r'.r u c c . QV A l`Z1 V=:�S`es'-4
Telephone# Fuca • q-7 f- oti,
Telephone#$ tl8 �%'7—S"3t3 Q(A
Type of Building lzz 5 Lot Size I -7.'4r 15 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder40
Other -Type of Building N No. of persons Showers ( ), Cafeteria ( )
Odter Fixtures
Design Flow (min. required) ''-� �� gpd Calculated design flow �`' �`'} Design flow provided 3 �4 •-7 gpd
Plan: Date l (A g' / 1 I Number of sheets Z Revision Date
Ti tie &i e(s._5-gG-1ZA Pd -FC .Sy e3 -P, -A C1�afyrLG i'(aLtl`Sn.clwc ✓d W is M-. -.>i•t,
Description of Soi(s) 1C' •39-- Sei l '�77— Ce
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Soil Evaluator Form No. Name of Soil Evaluator ,/ -U- Mt.GJni. , Date of Evaluation l6 1.Z I I
Ste- f- -c(Z
DESCRIPTION OF REPAIRSORALTERATIONS 6,er+4-tZ 4�...4 17 tscsr ct•-a
��c L ore c 4 (� �f� c „ytry 1 c� .t ° r G
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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 agree r6t to plae tt a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed / Date Nc?V' ei
Inspections
No
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�.. FEY.a b ''e X
COM[MIOMAL1I1 OF MASSACHUSETTS
p q J
Board of Health, , r:= i" ` NIA.
CERTIFICATE OF COMPLIANCF
Description of Work: ❑ Individual Component(s) p' Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,'v , Abandoned ( )
by:�,r
at
has been installed in` ccordan e with the provisions l 310 CMR 15.00 (Tide 5) and thea PP roved design plans/as-built plans relating to
application No. ix 'rx ? dated 11 J, , h : ' . Approved Design Flow , :°c� e (gpd)
Installer' i P ,.
Designer: _,
¢':: �. `,-. r;. �,: ..., Inspector:'"h'=:.: : -. �•+.', .t$ Date:
... ,.,... .e s
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. "
No k' ")� ti411 9 I -.^ C.i Pat h";J 0.:'w�' k."" x. (-l") tJ d FEE �i.o `.'^x (1t)
1 ` COMMONWEALTH Of MASSACIJUSFTTS 96
4 .
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PFRMIIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(N•) Abandon( )an individual sewage disposal system
at as described in the application for.
Disposal System Construction Permit No. 1 - 4^q , dated .M" ` c't 11.
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
4
Pnrm1255 Rev.5/96 A.M. Sulkln Co. Calo9M%MA Date .•"i✓l�51fy Board of Health `; .e'✓. �.'''°s�... �....rw'". �,.a