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HomeMy WebLinkAboutApp-Permit-ComplianceNu. COMIMIONWEALTH OF MASSACHUSETTS Boardoflleallh, N ffino�ak Am. FEE =� APPLICATION FOR.. DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ htdividual Components Location66 (fbbz/D lep. Owner's Namc�.Q/� LXGL F-gnn;L tM,tl--C- Map/Parcel#E3 tQ6 Address I Lot# Telephone# Installer's Nam p -q- 4 Designer's Name 112&„7 ,e/JDQA, �4 f Address . Address .9 d>CVF5 P Telephone# S6 jr-- Z6 - ZQ5' 11 Type of Building "� '� Lot Size sq. ft. Dwelling - No. of Bedrooms Z t` "Q Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required)Z-2-0 gpd Calbulated design Row Design flow providedZ!/4. % X gpd Pham Date 1- �, 7 h Number of sheets / Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS/) 20 '`''i' S'''gkzA-, Z d6 4t- The undersigned agr s to Inst a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agre o no to place a tem in operation until a Certificates of C%ppm' rice has been issued by the Board of Health. Signed t Date '2/7 Inspections tet- G t ALNo./ f f` COMMONWEALTH OF MIASSACIILISE Board ofHealtla, CERTIFICATE OF COMPLIANCE611 _ Description of Work:"' ©,Itidividual Component(s) ❑ Complete System a� ) '¢'� '• � 0 ~ v, 9 ct l ° The undersigned -hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ), Upgraded O) Abandon d ( �` by ✓� e bJd'? . 1 �" 's'`?d *? k'� 'fin —r'*. r.,^" v .��:,,., 47. at 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 'Hj application No. ! `"? - °� <.a ,dated d ' t (o " � �'' Appa o,ed Design Flow � /fie" (gpd) hist111et s �Inspector: a. ^.t ..-`�. Date: «^t"t*'° ».. ..-. :`•, i - The issuance of this permit shall not be construed as a guarantee that the system will function as designed. g, No. N o � a ,, FCL COMMONWEALTH OF MASSACHUSETTS Board (YHealth, A).4w `n -" k )T8 1- VIA. DISPOSAL SYSTE° CONSTRUCTION PERMIT A 60, Permission is hereby granted to; Construct( ) Repair(!,.)' Upgrade(L�) Abandon( ) an individual sewage disposal sy'e at,2/-, r /- i� r`'r /fit-"� f ,t'l . as described in the application for r Disposal System Construction Permit No. ri (J dated t s Provides): Construction shall be completed within three years of the date of this permit. All local conditions must be met. ° �Form 12ssRev. stesn.M.smkmCo. chadesimaMA Dates= fk Board of Health .,, � C", ` °�_.,° r °. �$,,,.••£ t � 93,:,.+x. t�. '` C a. YA