HomeMy WebLinkAboutApp-Permit-ComplianceNo,'-ro�c-l9-}Zs2 &cjT?—Z.0-oo3000 FEE �6rOo
I c — a-7 ®> M ONWEALT T OF MASSACHUSETTS QW t 2i N
to 1195KC-t-<C
Board tfHealth, Y&OMOLEnj MA.
APPLICATION FOP, DISPOSAL SYSTEM, CONSTRUCTION PERMIT
v" Application for a Permit to Construct( ) Repai Upgrade( ) Abandon( ) - Complete System ❑ Individual Components
Location 10 •
CV 000N !-A
Owner's Name AI/1/15 e,-Kad0
Map/Parcel#
a
Address ` 05 5
I.ot# a �(/
Telephone# 6.02215-71 -7,;?
Installer's Name
Designer's Name
Address
S, Y
Address nJ�j.-�••
IfTelephone#
Telephone# S (jt�'QJ
Type of Building 0,�n,den-T /Q / Lot Size f 000 sq. ft.
Dwelling - No. of Bedrooms 5 Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures r
Design Flow (min. required) ^��� gpd Calculated de/pyirg,n flow j6O Qd Al Design flow provided .Sc� o gpd
w
Plan: Date A/ } tir �'1 Number of sheets Revision Date
Tide / {
Description of Soil(s) 5e- G`y'%„� c? � rr l'1CG�tS�r�
Soil Evaluator Form No. Name of Soil Evaluator j %�Y,.6—n Date of Evaluation
DESCRIPTION OFREPAIRS JORALTERATIONS
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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 agrees to not to place the system in operation untila Certificate of Cfarpliaryce has �been issued by the Board of Health.
Signed Date I
Inspections '� G ) B✓
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COMMONWEALTH OF NSSACRUSETTS
8e Board ofHealt/a, ����llt'�` ,MA•
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Componen(s)
;
Complete System
The igned erebY certify that the Sewage Disposal System; Constructed Repaired wedO Upgraded
Abandoned ned
by: under, ,,,to
at sry ( )
/jo rlC4 377,71
has been instal ed inccoi�cc with the pr[o3visions��gfe310 CMR 15.00 (Title 5) an�l�ah e approved design plans/as-built plans relating to
application No. "+ �" "' , dated 114"Y °•`3k''` = .Approved Design Flowery •'3 (gpd)
Installer / pit,/. �'"' rgg'�.. �"• & ` & p.
Designer: e'12�.lP"a^ ,r'"...n.., Inspector: 8 pp
` .. Date: 0, F ' : t d s -f.
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No }a.�y7- x. ,.. _.. FEE 7� 51,; (i,)
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COMMONWEALTH OF MASSACHUSETTS " W}t°
Board of Health, �� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
...
Permission iso ereby gra ted to; Construct( ) Repatrk `(^s).._ Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 71 f' as described in the application for
Disposal System Construction Permit No.
:.>_.. i;.,..sC dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 6196 a M. smkin co. chadeMum, MA Date. l `"t �'-"•'alt%`" Board of Health / 7�. �' {"'1-•'"+t`