HomeMy WebLinkAboutApp-Permit-ComplianceNo. 80 -Dc -2D -2$S,
20 COMMONWEALTH OF MASSACHUSETTS
FEE
WY 6NLq Board ofxealth, /�2MoU'i�F MA. FEB 13 2020
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PE M1kALTH DEPT.
pplication for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) - 0 Complete System Individual Components
Location6V5jj:�jOwner's
Name Ry,Ao }= GuuSclhcc
Map/Parcel# SU
Address JO<,"7
Lot#
Telephone#
Installer's Name Vyry-f �C,`o` _
Designer's Name f� I
Address WFI,t 5, t$ttaLi
Address
Telephone# '5oF-1477 _
Telephone#
Type of Building (20t ti l,t_322c.Id4-t-. (l e4L'. Lot Size
Dwelling - No. of Bedrooms
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 flow
Number of sheets
Name of Soil Evaluator
sq. ft.
Garbage grinder( )
Showers( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS TN S-'04 ! _ Adtfy j MZF:a
f7p4;tL GdtJCAT OF St�•�"ti •�'7--T4ci�L
�''t?f-Es (lJ cwt✓`
W-10 Di T',-(:- I-IJ11-64 TILai..: G. iJ cSZ. 'Zxi �s a
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no o.,place dw system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date t.3h'<�C.�^t
Inspections
!111EL.;
No. �?_C , E .a"j`?
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 114 0 17.1- MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (V, Upgraded O, Abandoned ( )
by: f)o o . ..,. f.. lr,+a Z� u . L;'�t`) p „b.&
has been installedinace rd nfe with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. � Gi - 41 % ,dated .Approved Design Flow (gpd )
Installer ,,P^C_71 1:: oyp COO p t} +
Designer: i 4es Inspector:t i d �� .,�i( (t(i .., Date: l 0" l"1/'�
The issuance of this permit sball not be construed as a guarantee that'ihe system Will function as designed. y5
No. f.)'%!6 yi C «.:2,0 --.tom'., +.w^ t t`` .?h � k... (-`!a r FEE
COMMONWEALTH Of MASSACHUSETTS CJO` ` r
Board of Health, '144#14 0 0 n MA.
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( ) Repair(;A) Upgrade( ) Abandon( ) an individual sewage disposal system
at ( 6 1 P o e a= s • 115 �� as described in the application for
Disposal System Construction Permit No. Fl (' , dated
Provided: Construction shall be completed within three ,years of the date of this permit AILlocal conditions must be met.
M.
Form 1255 Rev. 5/96 Asul0.m Co, Mrden, MA Date 1 l 'Board ofHealih-