HomeMy WebLinkAboutApp-Permit-ComplianceW'110 L17 FEE
COMMONWEALTH OF MASSACHUSETTS A4j(0q6
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r—,/s,,�, 0 �1 �—'� Board of Health, MA. EB 2 4 2020
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PE If
HEALTH DEPT,
Application for a Permit to Construct( ) Repair(fUpgrade( ) Abandon( ❑ Complete System tIndividu omponen
Location
Owner's Name � , ce
Map/Parcel# 3 .1^t='O
(Lo
Address.313"Tri P'Y$2&t,. ` O 11,ZY
Lot#
Telephone#
Installer'sName
j
Designer's Name
Address�
St
Address �/�`�dfiQln') ^• lF
Telephone#
7clephone#,,'j0`d' �(�'y.SC}l
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (min. required) J -'l 0 gpd Calculated design flow
Plan: Date 4ro.b 2v_�ti Number of sheets
1 ✓
Title T, `( EN ;fi Sed. t es ti 11 pAr i / Auz 14 0-e-
Lot Size 6,52Yo sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided t gpd
°ision Date )5jZ0=,,e?O
.. .n
B °
Description of Soil(s) ?P_ :"-t-f' Aw
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS
The undersigned agrees to ins talk above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to Ike system in operafion until a Certificate of Com fiance has been issued by the Board of Health.
Signed- — Date---=':�
Gr
Inspections
No484Ci '-gib "° :v() FEE
r
COMMONWEALTH Of MASSACHUSETTS' �N �,` � c�ci -2
A:s'''t f'> i(..`t Board of Health, Y+-iAMQV/ 1 MA.
CERTIFICATE OF COMPLIANCE
Description of Work O Individual Component(s) Cl Complete System ��,,.""
The undersigned here certify that the Sewage Disposal System; Constru��cted ( ), Repaired G�);, Upgraded (t)"; Abandoned ( )
li' l' Y l a* . 'f` �` t� t 9- & s Y� @ 3 S Gil t i F rJe�6 y 8 V'C it'
at
has been installed in accordance with the pr Sion of 310 CMR 15.00 (Title 5) and jhe a proved design plans/as-built plans relating to
s is
application No `? P�,dated = `/� " F� .Approved Design Flow ) s (gpd)
t
Installer 4660
t`� h".� i. -O2 a W T7) UT1 t d P
'� ) ?,. , c,a .... a. .. _-`" Date: gg r
Designer: ..�'%4)Et)(,�,MC_fl�'�" (';,�f`+i�d�6� < Inspector:° a6 �.� °' (� "�' B �=._ $ 2{'-",.-'._a"7
The issuance of this permit shall not be construed as a guarantee that t7 -ie system.will.l;'urection as designed.
No. d."7imi Y.+tom-... a��,'.."':.✓ �%t�e .�.5.*t,wt G t( FEE "i (."i �»"5. C)
COMMONWEALTH OF MASSACHUSETTS ��1L1 A
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission ishereby granted to; Construct( ) Repair( ) Upgrade,(�t) Abandon( )an individual sewage disposal system
at P C NA(Pi A V :. ` as described in the application for
Disposal System Construction Permit No. Z V u C� dated U 7 L)
Provided: Construction shall be completed Tthin ree years of the date of this permit Allloca conditions must be met.
Board of Health.
Farm 1255 Rev. 5196 A.M. Sultrin Co. CFateslam,MA Date f (•) - �� -�••d` {dl !i -"'r'^''