HomeMy WebLinkAboutApp-Permit-Compliance604 1yC494O&Z- �51 0 t12- go- o09Z 3
No.
19 --,3 7'—/ COMMONWEALTH OF MASSACHUSETTS
j G I+ 1 A S�lBoard tfl-lealth, Yf gMQ(Jn-4- , MA.
�J APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑
FEE
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Location ct.
Fc / -1 /tet -P. e/% G,t/,i-
Owner's Name40�'� (t 'C7 /clF�,/,h.✓/�""`�-�:�•%
Map/Parcel# si
Address tt j�d+---� /c�l
Lot#nn
Telephone#
Installer's Name 1� f! � 1
VJt���1�4d- �'phs�•
Designer's Name 'S4," ppb &— ,>
Address a,3j
Address �/ 3 �•v -rJ
Telephone# �o�
Telephone# �'p$— 3 6 �QCf
r
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required) 330Jt gpd Calculated design flow
Plan: Date Number of slicers
Title
Description ofSoil(s) '
Soil Evaluator Form No,
G
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
P
Lot Size
No. of persons
sq. £t.
Ga'bage grinder ( )
Showers O, Cafeteria ( )
Design flow provided ' S2gpd
Revision Date
Date of Evaluation
The undersigned a res to stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t o pl the emApe it a Certificatep 7 has e r issued by the Board of Health.
Signed ✓°' i Date
19 -
No.
No "` i �'� t') («- i° .... � h„7 fw«.� FCL
tf COMMONWEALTH OF MASSACHUSETTS
r Board ofl-leolth, / ✓)fid%% MA.
r d CERTIFICATE SOF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: 1'11}I...a �cm`
ar,3.,' ""9$ '0'/-va 1-4t r° -t `^.F T,� t%p,z •1-.1 (. _ rMs !t-</ ,fir ;Vit.
has been install4IiIn accordance with the provisions ol„,310'CMR 15.00 (Tide 5) and the proved design plans/as-built plans relating to
application No. dt '-r/f w dated .t / t ` µ l<° Approved Design Flow �'."X:r't" (gpd)
r
Installer
art rk t , $ f �! . <l Cyz f.r,
Designer: `ti,.- 1 5 't i . ,. ,:� r``/= Inspector. v! �6 _; ^.P a: -' P e"� Date: r <[,n
' v u.• t 'Tc—..
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No %nti i`P td` ("' � `"' � � l...ec='a ?(tt.l�,.'y FEE �J }
COMMONWEALTH OE MASSACHUSETTS
p d Board of Health, ydll8im MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at �).."Jl.r ';`iasdescribed inthe application for
k"
Disposal System Construction Permit No.dl-.- 2.':'%7, dated-
Provided:
ated-
Provided: Construction sliall be completed within three years of die date of.tis permit. All local conditions Hurst be met.
Form 1255 Rev. 5196 A.M. Solkin Co. ChadeWNR MA Date i1 Fr�-7 Board of Health