HomeMy WebLinkAboutApp-Permit-Compliance`(3 G�iD�'�c1'O6Zj
e0C Bice —7_U -001S -8Z
COMMONWEALTH OF MASSACHUSETTS
FLE7 �. W
66ad—
Board(f1lealth, YH-P—
APPLICATION FOR DISPOSAL
Application for a Permit to Const uctK Repair( ) Upgrade( )
loo H ,AM.
SYSTEM CONSTRUCTION PE
Abandon( ❑ Complete System 41ndivl
RECEWED
MI�'Ep 2 02019
ual Components
HEALTH DEPT.
Location
�� CiOG.�E'ZC
D
Owner's NameQ.>
Map/Parcel#
1? '77
Address a4 Z* (ZO Gprr"y A
Lot#
Telephone#
Installer's Name SG€q ►(/s'i tV
67(..a,l4}-Til)
Designer's Name LCIAS�r4qt, /Nt{:MA1
Address13
.SPC--a.'�/
1C�
Address 2bu 3 im1 '1�1vY i1 .S
Telephone#_5Lir
3Z a
Telephone# S'pI 2j5— Gs?)
Type of Building X/ 610AJ ( Lot Size Zi 66--3 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other FIXLUCes
Design Flow (ruin. required) gpd Calculated design Bow — Design flow provided
Plan: Date 17117/13 Number of sheets 1 Revision Date —
Title
Description of Soil(s) A//A
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1 ,iZV SJ—( (H-20) '- n ^ 2 u I')So,<
gpd
The undell tgned agr to inst described Individual Sewage Disposal System in accordance with due provisions of TITLE 5 and
father afire to not pla t [em ui eraton until a Cer�ti/ficate of C plia ee has been issued by clue Board of Health.
Signed �� Z
//`` i at'e
COMMONWEALTH OF MASSACHUSETTS leI
�s s `A "
cc ! t +
Board afxeard, 03i1t;11 9 MA.�r1
f CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System If
The
FEE 5;--6,--06
hereby certify that the Sewage Disposal System; Constructed ( ), Repaired-( ), Upgraded,(''), Abandoned ( )
by..,`/ 'v, ",F-. . — ,. ', 1, -
has been installed in
application No. p
Installer . A -m
with the proviions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
dated !Q> evwI ) . Approved Design Flow (gpd)
Designer: 8o /%7-A' Hnspector: 424, ., t a';.: +
?
Date: _
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. "
>e COMMONWEALTH OF MASSACHUSETTS
a7 -� Board of Health, �'elWTI+ MA.
d
FEE
m
DISPOSAL SYSTEM CONSTRUCTION PERMIT
X11
Permission is hereby granted to; Construct( ) Repair( ) UpgradeO Abandon( ) an individual sewage disposal system
at 4'
_ as described in the application for
Disposal System Construction Permit No. 42? , dated r.'J <a ✓ d'
Provided: Construction shall be completed within three years of the date of this permit All local conditions must be met.
Form 1255 flow. 5186 A.M. Sulkin Co. Clmdeelm9 MA Dates .� � Ppr"/l� Board of Health rt✓t s 'i