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HomeMy WebLinkAboutApp-Permit-ComplianceNo.�,.VDMI _j 1e5 01 13eG' (-)6;67P ek�51R- 2-0- OD 3 5)COMMONWEALTH ©F MASSACHUSETTS tT Board t f fleallh, � 0 v l r l MA. ,6GDP-2o—Qo3�`I V 1,7 _a qeP, APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION I)EC 102019 Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location j'Zj� Owner's Name 1 h� Map/Parccl# 54 -1 -7 Address �'L, 1 Lodi Telephonelt Installer's Name c' WtILDIV, Designer's Name Address �r� Address'MA Telephone# noo- - z�j TelephonC# rd Type of Building t 1 Dwelling - No. of Bedrooms 2 Other -Type of Building No. of persons Lot Size sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) other Fixtures Design Flow (rain. 1eq tired) gpd Calculated design flow _� Design flow provided ��� gpd Plan: Date -T I )_1.�wa i _____... Number of sheets_ I Revision Date Title V11 Vi ­ Description of Soil(s) _ Soil Evaluator Form No. DESCRIPTION OF Name, of Soil Evalnator Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further •ee o not t pI ce tit ystem i t operati n until a Certificate of omlllimce has been issued by the Board of Health. Signed Date Inspections No. Y':� ±/d.. B8t r_.. n c.°». FE y'}:bZ 00 COMMONWEALTH OF MASSACHUSETTS `r ` Boardo/I-leallh, g kEtyrvtfl(i��a MA16 P �Jr. p-ra,a - CERTIFIC'SH 01. COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete SystemUt16s'7- The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (~ ), Abandoned O a by: k1C�ln". 11 i at �` A.A C- has been installed in accordance with the pr , visto is of 310 CMR 1.5.00 (Tide 5) and the approved design plans/as-built plans relating to t application No. `"i'+`'i.J dated fad' i Approved Design Flow I (gpd) Installer 5' Designer: a. ` ,".et� 1'"' Inspecton;, f A ,, J' _--- Dater The issuance of this permit shall not be construed as a guarantee that tite systim,�`4ill function as designed. No. C®ISI ONWFALTH OF MASSACHUSETTS r Board of Health, 1! �' <.il( 4;) i MA. DISPOSAL S�'STI ASI CONSTRUCTION PI;RNIIT I's I' - FEE a� Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at I E�•�;'' °�`� `�`�'"`4.�"" i,.'` as described in the application for s-- e, Disposal System Construction Permit Nof 1 - )` r L' , dated 0 •, ' `::= . 1 Provided: Construction shall be completed within three years of the date of tthis p/ (egr%t tt. All local conditions must be met. Form 1255 Rev. 5196 A.M. §olkln Co. Chadestarvn,MA Dated > l.�'=ti�'�al � Board of Health i .� t �* W