HomeMy WebLinkAboutApp-Permit-ComplianceNo. e0wDC-?,D-ZC5,'
20 -011
COMMONWEALTH OF MASSACHUSETTS
Board ofHealth, �.FlgMf dTW , MA.
x PLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) - O Complete System
FEE 463� t0
2«s�
Location (0lp1
Owner's Name tjd,� � d et. U. = 5
Map/Parcel# '�j
Address ltd -1 9, P
Lot#
Telephone#
Installer's Name
ec,
Designer's Name 1A
Address 3L_,3
Address
Telephone# 50
. 7-7
Telephone#
Type of Building (2,) ",;4 u DL e—( ASL-- ( FIRC)o.;7 5V 5-rG PA / ' Lot Size sq. ft.
Dwelling -No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
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,
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONSa-Ns"t"-� 14) tq,l �' ' : .L,- k- W Imo" E
I Qotj C `)UCl° 7rn' L
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire s\to n�t-tp\place a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed '' 'x +a_(,_s;./'_'.. Date jL611�
Inspections
No )°)omx- e,`--e°t-}`,53 FEE Y^"ai .
COMMONWEALTH OF MASSfACHUSETTS `;3_2 cera t
Board of Health, 14 MA.
CERTIFICfATE OF COMPLIANCE
Description of Work: U Individual Component(s) Cl Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (m, Upgraded( ),Abandoned( )
by.raeb iota
y_ 8
at 9d P "f it r•) o `Y� ,ri7r `�-,A, -,.-ep, ) urs
has been installed inaccordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 7i! ` 0- l-� , dated ,�^' Approved Design Flow (gpd)
Installer f"'*" n s 'a7"X"` 4 `, ,.s,,,2 e... o
Designer: 1A- Inspector's 1 ;"111 rkl, Date: -�- �'2-."7 ;) a ell? 1
The issuance of this permit shall not be construed as a guarantee that -the°system wi(I function as designed.
No. �.".til E -i i'}f".-w?t1-..C>?'; t_. 1`, �.)L.J t""-__, FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, VA(2f7 f Q U-1—WMA. r � ` �t l � I
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is
1 at G6
to; Construct( ) Repair() Upgrade( ) Abandon( ) an individual sewage disposal system
,r
Disposal System Construction Permit No. dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit All loc4conditions must be met.
Form 1255 Rev. 5196 A.M. SuMin Co. Clatesoes MA Date � i �F�1 ^��� Board of Health �--"'lkl !.f' ^`i .�. -^• �"°`