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Home My WebLink AboutApp-Permit-ComplianceNo. RZI FEE ��OD d30NDc—f�r—I� �9 COMMONWEALTI-I OF MASSACHUSETTS r_c 0578 Board ofHealth, _U jbh)19� i MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, T OCI � 0 2019 FIc, ''!11i_pI- Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - 0 Complete System ❑ Individual Location C, �_k(_ O P, Owner's Name 15 Map/Parcel# 9j164 Address r Ci CoRrJ. ( rnn(7d T 11 C• Lot# Telephone# 5 j'K- (a ._'�Ct4'� Installer's Name R06-_ j y C�7�"� tv(�j Designer's Name Gewo C.pz EN)rlJ.) e- (, Address vo UO`.� IJ �} 1(yry )�C�. ©c�.. t�' AddressJit(o+`'RrMCJ'3� oil A Telephone# 2__ Lj tjj Type of Building ] Dwelling -No. of Bedrooms 3 Other -Type of Building No. of persons other Fixtures r �� Lot Size Dit_sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design Flow (min. �a�cquired) D I U gpd Calculated design flow 33o Design How provided Plan: Date c7� �� ✓ 12 Number of sheets 3 Revision Date Title �y®�� ,.�.p Description ofSoil(s) At); 1-ivC}�{IA6-- (..(?hA^,q A:c i ('_ NtC'T-1 _f1A) &,eCILtsJ4� Soil Evaluator Form No. Name of Soil Evaluator &4 VCA] FTC P3 f Date of Evaluation DESCRIPTION OPREPAIR.SORAITERATIONS NJ�cGbl �1- o ('"i,t{) �k r tV� S�Ars-G'A f ro L yr A -o ma a ! gpd 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 phh system in operation until a Certificate of Comp/fiance has been issued by the Board of Health. Signed/y- Date (IICj n`� P"cu�— So. Inspections % � � 4 ` f` t ' �� e>I G 1< -. / t Vii- , q +, , Ne�)t?�_¢7( 6 (6C) � FE " � COMMONWEALTH OF MASSA�RUShTTb Board of Plealth, �✓1 a"-'2. h d) SQA, &IA• J p �I ICERTIF!5ATE OF COMPLIANCE Description of Work. O Individual Component(g) Complete System �„,< w 1- k 1 The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgracted�(,, Abandoned by; DoR at r-§ JAL i C._'� K0, , has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to application No..="e" " cx�<++�.' dated _v /°S"". Approved Design Flow :M., "e (gpd) Installe qq( 6 ° �-t' r- i.. / 7 /r)t t Alt w"r"id' linspector: R• r t u: (.l.N`a Date: d r _ ) tit d The issuance of this permit shall nol be construed as a guarantee that the system will function as designed. ! pp No E FPC ' yr{, t w COMM, ONWI ALTH OF MASSACHUSETTS BoardofHealUy Vfj4b 01j dU MA. DISPOSAL SYSTEM 'CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( )ry Upgrade(,=) Abandon( ) an individual sewage disposal system at ("'fll(._. C, t l Pl e!' as described in the application for � / e � Disposal System Construction Permit No. � `i` " & "a , dated / f i Provided: Construction shall be completed wii)hin three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/88 A.M. Sulkin Co. ChAlafn, MA Date (l � ' ®fes Board of Health =t -1a '{"