HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60 4DC -f9-130-7
49 — ZX -75 COMMONWEALTH OF MASSACHUSETTS
Board of Health, `49ML) VT , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - 0 Complete System
2 W11019
Location 5
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7--e-( Owner's Name RtjeX_-- -,.'C P t ktZ(_L1
Map/Parcel#
64 ZL
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Address 5 . pe _ &51"Loc=, &�.�`
Lot#
Telephone#
Installer's Name
t ` �e
&(4: Desigher's Name tV 4
Address N-�
-, Address
Telephone#
—4&7-7—r; Z'7
Telephone# ji
Type of Building _r_GG� D6 ?1 SL 4 /E-('
Dwelling -No.of Bedrooms 7
Other -Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
_ gpd Calculated design Bow
Number of sheets
Name or Soil Evaluator
Lot Size 40, 07 5+ sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ��US�%P-�..rVC��LC.J i*—Io
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees two not it ce the%system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed I \ Date
No. 1:..,a° } �"`Y kw+t- ""� 9-1 •^� i� FEE `tF%�R•h. ia. 01
COMMONWEALTH OF MASSACHUSETTS , , 1 ��c,
Board of Health, MA.
CERTIFICATE OF COMPLIANCE rq �x �• � K� ���oa`�
Description of Work: A. Individual Component(s) Cl Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired � , Upgraded ( ), Abandoned ( )
by: �'d "ft'..kt' a: .. eY. ""ka^r- Q /5 JL e r-) +"Z
at.
has been installed in accordance with the provi ions o �0 CMR 15.00 (Title 5) and die approved design plans/as-built plans relating to
application No. � d. 7f ,dated A r Approved Design Flow —" (gpd)
Installer•/ t7 raar' '.*r"" t_ /"ra1'� (ps aal/ ,x.1.1 t�A7'a) p
Designer: h,..)Jt,✓')t- Inspector: hf2, + Date: re
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ' 0it-"..c.19 _1 30-1 C.r-TeCwt-1) ePer.. S-•" FEE
COMMONWEALTH OE MASSACHUSETTS cj1= ' (em («I
Board of Health, ;lel MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(A) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at�i do t"a",.'-t'�,a'`^� i ^ f- !'�'m'al as described in the application for
Disposal System Construction Permit No. 147-r9 75 , dated �A ro,✓,d .
s
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5196 A.M. SmIXIn Co. Chadaalaa, W Date 9 ), / Board of Health `P Few •'`;'