HomeMy WebLinkAboutApp-Permit-ComplianceNo. grim) E+Q Fc v0 1 V_Aerm
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T-P-NV_1,PR0x oNL1 COA'lid'IONWEALTH OP MASSACILISETTS
Board if Health, /a'%L%VLd l nW , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Rcpair(� Upgrade( ) Abandon( ) - ❑ Complete System X1
0 8 2020
Location 39 -= '_ G
Owncr's Namc3AES g QARz- t Cu)c_C-(h)S
Map/Parcel# 13 c J q -
Address '?j9
Lot#
Telephone#
Installer's Name R p .-a ( Ova- (�
Designer's Name
Address 3(�3 (-diEt'Y -P LuTt'
Address
Telephone# J�t7 y _ t� �1."-Cj 3CJ
Telephone#
Type of Building SSC G t p`i-L-- Lot Size —,:x3, Si ��-- sq. ft.
Dwelling -No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers Cafeteria ( )
ocher Fixtures
Design Flow (min. required)
Plan: Date
Title
_gpd Calculated design flow
Number of sheets
Design flow provided
Revision Date
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
gpd
DESCRIPTION OF REPAIRS ORAITERATIONS 'V�J sTvk c_ (SL. C -Ace -a&) Soli 1 c--('p�tlOK
-m N e c& 7 co (Tu- RtS' r2S A -es
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place die system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 1,.'.�,..S1, C ---1= Date
Inspections
No. k�a1-8 �ir..C)--e:'C)4 f_7 FEE
7. _ (� COMMONWEALTH LTH OF MASSACHUSETTS
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Board of Health, �,f��+2(bC TR�✓
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CERTIFICATE OF COMPLIANCE
Description of Work: X Individual Component(s) ❑ Complete System tT�
The undersigned hereby certify that the Sewage Disposal System, Constructed ( ), Repaired`}, Upgraded( ), Abandoned ( )
�ry
by: yt (3 P t
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No d.% - (1 `'A , dated Approved Design Flow (gpd)
Installer ea��' C!
"Designer: ar i'."C" t=.. .�. _..., t :'
7,
g Inspectoc�� � ice,- -sill(,),r `�na t �"?� Date: 1 1 .:•, i C.::>
The issuance of this permit shall not be construed as a guarantee that. the system will-l�imction as designed.7-1
No 'Q'"f)l'S tit e` ciw C�cl �1 i" (�„) '•(C°�, FEE "'kti �`� 1
COMMONWEALTH Of MASSACHUSETTS� ��a it(
a,
Board of Health, �l �¢jC Ot �'&"�h MA. ) I'`Jh
F
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repait-A) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at Q�wmi,. ��•,�figvsJRA�"^�'ra,*'I- s '" 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.
g � a
Form 1255 Rev. 5196 A.M. sm[rn co. Ghftonn, tun Date Boardof I3ealth' 11�, ,h`6'p -:e "a'.e,
