HomeMy WebLinkAboutApp-Permit-Compliance±No. '661+Dc—ZO -Zgol
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20-0q COMMONWEALTH OF MASSAC14USETTS CXFF101 g
Boardtfflealtla, *("rMDU-*\ MA. �CIS90W1-aD
APPLICATION FOR DISPOSAL SYSTEM CONS TI RUCTION PER IT FEB 10 2020
Application fora Permit to ConStrUCt(YJ Rcpair( ) Upgrade( ) Abandon( - @ Complete System ❑ Individu Coplpp�Zep�{ DEPT
Location $
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Owner's Name Zn r',a MPlaone.
Map/Parcel#
y 9 b �
Address S C', rO U\ F (l Oox ab}
Lot# 12. 0
Telephone#
Installer's Name � Q LY C611a}�0n �t16-
Designer's Name F\OV\eA 4,PW\romer\vq,l
Address 3�j
KOUAr, 130 Sandw�t.l�, MG.
Address RO. (30x W,\6l Ma
Telephone#
Sag. q17. 0653
Telephone# 4-4y• 9M. 11b(o
Type of Building P1e5. D LJe.((tnq Lot Size S, (b0 sq. ft.*
Dwelling -No. of Bedrooms Z Garbage grinder (uta
Other -Type of Building _ No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ZZo' gpd Calculated design flow Design flow provided 30 gpd
Plan: Date Z -7 2.0 Number of sheets Z Revision Date
Title
Description OfSoil(s) See, P(an3
Soil Evaluator Form No. SE Lf 2. 755 Name of Soil Evaluator D. f j0.her; y Date of Evaluation (eb- S- 20 Zp
DESCRIPTION OF REPAIRS ORAITERATIONS irl5}Q\1 r1eW \$00 gw1(on See it,-ian , ti- hoX rand SAS.
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre};ta not t p hcc the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed (/ n'" Date 2/10110w
/ 7l /
Inspec 2,1 w -"s 1)�) 47,,nL ��l ( {i�(-PA ke i In
No. F"i.1 ?.C.'X FEE
COMMONWEALTH SOF MASSACHUSETTS � -AL lo 6t<
Board gfHealth, ��+..oc"i r, MA.
CERTIFICATE OF COMPLIMNCE
Description of Work: Q Individual Component(s) Ef Complete System
The undersigned hereby certify that else Sewage Disposal System; Constructed (4 Repaired ( ), Upgraded O, Abandoned ( )
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. dated -411 r it .'t'? . Approved Design Flow (gpd)
Installer ('
i+ px
„ F
Designer: Pr'o, ; 1.. i' iw,fn _ Inspector' �r, Date:
The issuance of this permit shall not be construed as a guarantee dine[he system will function as designed.
No. Povvvc
COMMONWEALTH OF MASSACHUSETTS J, `-�° I
Board of Health, 4)'iir�t� MA.
DISPOSAL SYSTFM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(\f/) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at i as described in the application for
Disposal System Construction Permit No. A O 0 1 , dated '1..Ito
e t
Provided: Construction shall be completed within three years of the date of this permit All local, conditions must be met.
1
Form 1255 Rev. 5/96 F.M.smk;n00.alutesowo,MA Dates I �' f :�!'' Board of Health . d .- C, `