HomeMy WebLinkAboutApp-Permit-ComplianceNei' 0Wpc-fq—oO/5� BCDTF-'ozo`.0013 FEE
COMMONWEALTH OF MASSACHUSETTS LMII)EP
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Board r f Health, )LA9 1A1 APPLICATION ➢AOR DISPOSAL SYSTI�'[i CONSTRUCTION PI019
Application for a Permit to Construct( ) Repair( ) Upgrade( ) AbandonO - ❑CompleteSystem 01ndivEPT.
Location S a 0
Owncr's Nam, 6W7%
Map/Parcel# / S
Address F— 13 u f
APL f
Look
Telephone# '5—v -+ c-� t/
Q'6 7
Installer's Name 1;-116 74 j- C
Designer's Name
Address j r
Address �'V
.[:Tel ephone#
Tcleoluneik- 3 �a ys'[�
Type of Building
Dwelling - No. of Bedroo
Other -Type of Building
Other Fixtures
Design Flow (min. rcquii
Plan: Date %..r
Description of Soil(s) y`,
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Lot Size / VCl�,/ S sq. ft.
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Garbage grinder (/}✓/�`
No. of persons Showers ( ), Cafeteria ( )
Calculated design flow `5 Sri Design flow provided 3 3 L� god
uL
The undersigned agrees to stall a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t,�c���, tit et o til- ertificate of m Lance has been issued b the Board of Heald..
Signed // "if�'i L/- Date y
Inspections
COMMONWEALTH OF MASSACHUSETTSb
FEE-,,
Board of Heallh, VA0116024' 024' , MA. L, (-7 C,,C (-,
CERTIRICNIE OF COMPLIANCE(-,
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Description of Work: Cl Individual Component(s) l] Complete System F<
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired O, Upgraded(t Abandoned ( )
at l "l h <+JR, 1::,t; flE ¢. l? ;w i- K R,
has been installed in accordance with the pr vision" 0'410 CMR 15.00 (Title 5) and tl}e approved design plans/as-built plans relating to
application No. 1 c) 01.7 1 dated.Approved Design Flow -5
(gpd)
Installer
Designer: ,r "+ ' r,. w
Inspecr ti^ t e f't DTfl .. & D. : x-
c� . �� t
The issuance of this permit shall not be construed as a guarantee tlmt"t{� )�he system will function as designed.
Nry o.i.
$.,•7�1'StY,)d•a,g „-%�`„ tit . ✓ 1 ( t`
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f COMMON ALTI-I OF MI ASSACIIUSE TTS ,l
Board ofHealth,
i
s•' r DISPOSAL SYSTI;I�(i CONSTRUCTION PERMIT
FEE
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Permission is herebygranted to; Construct( ) Repair( ) Upgrade(45 Abandon( ) an individual sewage disposal system
atS"a C�,. ).-"•;i 4l ),^ 6 .1 8r . ,. ','. t' . `i t,- r`L �'; ; t� i-"� f)G, I, t , ,"i' 7 6', as described in the application for
�
Disposal System Construction Permit No. i cki ` 2-21 , dated Y /
Provided: Construction shall be completed within three years of the date 3-ff,tthhis,permit, All local conditions must be met.
/Board of Health o
Farm 1255 Rev, 5196 A.M. sulkin Co. Ctaleslaxn,tlA Date (.✓ " �' "✓ },t »C ��