HomeMy WebLinkAboutApp-Permit-ComplianceC71 -
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'p c- l 9-13 (05CO1MMIONWEA LTH OF MASSACHUSETTS
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Board (f Health,jMO 0-1 MA.
PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIOT
Application for a Permit to Construct( ) Rcpair( ) Upgrade( ) Abandon( ) - ❑ Complete System
P, If 2019
HEALTH DEPT.
Location CPA PT
se R(`
Owner's Name o lwoo r
Map/Parcel#
Address 11 1 CA rx, R(.L . .:V rzAArxf,-/j
Lot#
Telephone,#
Installer's Name �(� ti --�" (7� �' r"'� r•
Designer's}Na C�-'Ivy FI J. ',<�S �C
Address O�� • ` 3 6411
(m�e
Address i0 IJCS C , pmk I-� �. f- 0
Telcphoneik
Telephone# �"" �� � L _ ('7L� t
Type of Building Lot Size / %L�., sq. £t.
Dwelling -No.of Bedroomse g grinder
( )
Garba c
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other FiXLures .
Design Iow (min. )required) gpd Calculated design flow l Design flow provided 137c) gpd
Plan: Date 4 Number of sheets _ Revision Date
Title
Description ofSoil(s) Q
Soil Evaluator Form No.
Name of Soil
DESCRIPTION OFREPAIRSORAITERATIONS ':
Date of Evaluation
The undersigned agrees to install a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place tem peraGon until a Certificate of Compliance has been issued by due Board of Health.
Signed i Date r �_
Inspections I i l � 1 I+ `7 J C,"`'+ 721"-1 /C r St FZ i) 66Y t 5-44r
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No oobcw�i� 1 �,(q w e FEE k7,Yw e)�°�
LOMIMIONWEALTII OF MASSACHUSETTS
Board of77ealth, fOF bit;433 R h1A•
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CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System,\
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The undersigned hereby cen ify,.rKat the Sewage Disposal System; Constructed ( ), Repaired O, Upgraded)(*), Abandoned ( )
by:
at
has been installed in accordance: with the r'p,� ions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. /9 dated'i Approved Design Flow gpd)
Installer i 41`i >� l° ' f• f ?�� E. Q ", ::"n y
"r]t;'s;_z`'£ie•.
C.
Designer:t�,i' &t.r r.„'4t Inspector:
Date:
P ..l
The issuance of this permit shall not be construed as a guarantee that the
^hegspy�stem will function as designed.
No .ht t_�y () . "I9-1 �, law,,. 0z”?>v" �A�..Rl, FEE
m COWONWEALTIT OF MASSACIJUSFTTS a
Board of Health, h-ji' dl'(0 3 R -r MA.
DISPOSAL SYSTEM CONSTRUCTION AERMIIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( Abandon( ) an individual sewage disposal system
1' 3
at ( s"i t..,)iY�,a.f_ `. as described in the application for
Disposal System Construction Permit No. ,->> ", dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Farm 1255 Nov. 5196 A.M.SWIM Co. ChetleAOxgh'A Date/ ? C' "d Board Of Health. 1
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