HomeMy WebLinkAboutApp-Permit-ComplianceNo.,1.D� I [Z_ '} rj"C'J�3�CcA) FEE P 1U.�C.C../
1 7— J79 —
Board rfFlealth, . f%iL l-1' , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PI RMIAV 2 6 2019
Application fora Permit to Consu-uct( ) Repair( ) Upgrade( ) Abandon( ❑ Complete System 0I1ids i dual gotnponenti,.,_
Location•r?,l ,t- t ) 1i y
C ( i--� l Y`_'
Owner's Name Ot d i7 ( fV•f -�
Map/Parcel#
f�C7h
Address„y-yJe A(rJ, tf,t°Ja bAj
Lotlk
Telephone# Cc `(-, - C
Installer's Name R0�tv,c- -5«
� . 0»Cw- Cc) ,
Designer's Name 0(x vJ !) Cfi[',
Address
`HoWvl"\0,1
Address1)06r"clss1 Mc �J
(9 AltoSi.c eelcvt" 1 cc;d
Telephone# 5o' ,'-L -0v":,� o
j -j(,;. « 1iCria'
Type of Building L 3 (3edy o tY�,n RLot Size sq. ft.
Dwelling - No. of Bedrooms .� �t'� (-:., i-J'f LP`~r✓-Cr3c.'�c°•('y� Garbage grinder
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
r
Design Flow (min/.. required) / / �7 gpd Calculated design flow G.tll-l0 Design flow provided L.1..l 0 gpd
Plan: Date I' }�+�) �i Number of sheets _ Revision Date
Title
Description ofSoil (s) 1"t 1�,6c)'i�ra -(,t�r1.'t"�j JX1nt''t !� l'�LtiC12r;an}"-ti,�R��k ilYdAC� �ft>ri`Z,,7nJ ,fd/dt'C�g S�tnJc
i
Soil Evaluator Form No. Name of Soil Evaluator /d "A,) I P "J H b ti Date of L' valuation Gh-i
DESCRIPTION OFREPAIRS ORALTERATIONS
ev-) nn, i in 0 6A n 1V C
tiJ
The undersigned agrees to install Ute above qescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place d} tem t ept•ation until a Certificate of Co fiance has been issued by the Board of Health.
Signed .°^°� i'�-1 iR-f''/? Date L ,� ;,�
a a
Inspections
No. C. o
y COMMONWEALTH OF MASSACHUSETTS
�) q,, t,»,..�`"Mµ�� b 4w" 4o -d w✓ d.°"
Board ofFlealth, pr 7i,3 MA.
CERTIFICATE OF COMP.1
Description of Work: ❑ Individual Component(s) O Complete System q
t
The undersigned hereby certifX that the Sewage Disposal System; Constructed (4, Repaired ( ), Upgraded ( ),Abandoned(
by; kjluto,zC < )a . ou (.- i°, .
at ' 1 ^ ^ a1 d &-' I *1 A v` ( C_
has been installed in accordance with the provisions of,310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
..
application No. +�tA ��• .ey ,dated r / �'a•'°`""",a°°.! .Approved Design Flow "'d t•1r,' (gpd)
Installer da?v=�". a°. C'"""C• �'., ("tlt..�£",'. C�.^,. ::C;hJ t,...• ..e
m
+ .« s�' Date:
Designer:,�'e�tN Is(d a`'..tR`9Ne1a'x,�ar1an4tttInspecwr: * ✓`'r v 4� t � .
Thejissugance. of this permit shag riot be mnstrueFl as. a
guarantee,that the sy..st.e..m
. will function as designed.
lNo. . ......
FEC , C(
COMMONWEALTH Of MASSACHUSETTS
Board of Health, VaLW 801�4 NUI.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
a
Permission isherebygrantedto; Construct(lef Repair( ) Upgrade( ) Abandon( )an individual sewage disposal system
at i- rl t fys ,t ,0 (N i c• C as described in the application for
Disposal System Construction Permit No. IV"f , dated 6'zOL;,7/1 "ry
I
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met
t t2 ((c".*' r"
(.,�«
Form 1255 Rev. sass A.M. smkm co. cludeAae !� MA Date PI/;t^`, eX/r' Board of Health vyy