HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6 V�DC—H—" iv1
/ `� — aRy COMMONWEALTH OF MASSACHUSETTS
Board of fleallh, 1 ar-m ouA7b 'Am.
FEF 66:0
e144
APPLICATION FOR �DISP'OSAL SYSTEMCONSTRUCTION PERMIT
Application for a Permit to Construct.( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System 0Individual Components
Location 'r'C?�r,*�'
l v(,1
Owner's Name E ( I S L,) ptL
Map/Parcel# 036
Address IN Lafibfbn %'!t gq W Ft 39/6'1
Lot#
Telephone# sog � q2 (p
Installer's Name Dupe MWh k) 6-, A-Ct- S
Chtt&
Designer's Name
Address i`;r Na/Xt.Jtae rin1+<° S f1441j ' RA
DY�.GG
Address
Telephone# �(3$-i7Co -3H79
Telephone#
Type of Building
Dwelling -No. of Bedrooms
Other -Type of Building _
Other Fixtures
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheers Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. ) Name. of Soil Evaluator
PlSzsS ezS r14c'2� ' �C �i
DESCRIPTION OF REPAIRS OR ALTERATIONS lof��
The undersigned afire stall the above scribed Individual Sewage Dis
further agrees to t to the erat' until a Certificate of
Signed 5Kn Date _
InSnectionS
Date of Evaluation
/ 77ie
I 4-00,5- 12 i07—/l44, .S)
d System in accordance with the provrs.ons of TITLE 5 and
plian�een//y'f��sfny'ed by lite Board of Health.
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,N� _� ti5ne �i /d,,o✓K �f/3011`/ 4— Ke-vK'r-d !ol-kr
i COMMONWEALTH OF MA SSAC�-���US1C1�'� ��'� FFt �^9� et_
Board q Health, N'A�/!d0¢ YT4 MA.
CERTIFICATE OF COMPLIANCE
Description of Work:Individual Component(s) ❑ Complete System y,'d a <�
The undersigned here 'k certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )„
by:C
has been installed in accordance with the
application No. - , dated _
Installer +.-ftI'1a l IA W. !NAN
of 310 CMR 1.5.00 (Tide 5) and the approved design plans/as-built plans relating to
Approved Design Flow .._.,.d._."-.-.-..-« (gpd)
T
Designer: .... v""""'-"'-"'. Inspector: &'W F ,'.r,'d Date; t
a t
The issuance of tiffs permit shall not be construed as a guarantee that the system will function as designed.
ddd y 1' p
",." t,J t 9/ f."i €-f- �..1 �� y i... 41 e:.:..i�...Ji-.,_ FEE
No. 66
COMMONWEALTH OF MASSACHUSETTS
Board ofHealih, ` 1u? 1tW7 !- MA.
8 ..
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT �� � �� M t �-
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at ) tl (O c)oy." - I L.1- L/`,W. � as described in the application for
i
Disposal System Construction Permit No. , dated t^^.
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkln Co. Ch rteemn, 644 Date 6 i i,:, Board of Health