HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1304,C)C-{ 1 -mo i6a 1 tom.- 2v`00 f 63 / PCC
i c� _ ajy2— COMMONWEALTH Of MASSACHUSETTS 16oi7
Board of Health, VPl&Ol)i4' MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair/ Upgrade( ) Abandon( ) - o/complete System ❑ Individual Components
Location '
_ �j0, ,r �
Owner's Name I f4-iWL-IVCX' U
Map/Parcel# G
Address (x/.37. ; a, S(-.Ac-c"Jet-t0p,-
Lollt-39
Telephone# (e
Installer's Name t Ol',fp�� lC .
Designer's Name CiJn l QUJLL L
AddressP,p,&X r?Vq At`si-UPt'SMiI U D qS
Address q �{"- 1 tcc o 0>4'?'S
Telephone# 5�,S _ r?!)3�q
Telephone# S0 3(p.�. ({5"y�
Type of Building
Dwelling - No. of Bedrooms 3
Other -Type of Building _ No. of parsons_
Other Fixtures
Design Flow (min. required) 30 gpd Calculated design flow
Plan: DatoSL i ../,?, POO Number of sheets
Title ',"w
Description ofSoil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
3
/, Ny% ±
Lot Size sq. ft.
Garbage grinder (\,YJ
Showers ( ), Cafeteria ( )
Design flow provided 36 gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS / tjV4,tQ4 L U in.l I( -C( C/Le ( —
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 the system in eration until a Certificate of Complirce has been issued by the Board of Health.
Signed Date.
No,,.''.'1�,"g ICE r b )
COMMONWEALTH1�IMASSACHUSETTSt fs (" G,0
Board ofHealtll, YA,12l l)!" 9` NIA
i� CERTIFICATE OF COMPLIANCE � `m:) � ��
Description of Work: ❑ Individual Component(s) M Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired k), Upgraded „:Abandoned ( ).
at Mt t,- - v
has been installed in accordance widII the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
a
application No l r)'c-,1A "A dated c 1,1 r'�` Approved Design Flow 411? (gpd) .
Installer
Designer,"Gorsn . i l.,.,r "w,. ,`.z`r , ,`,,. JX]r htspector ,`"I"7�t €.t':• Date: f
e
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. F a
No., ". w�+='i bf)(enax-m` l C m4A e0r_, -j0il PEE •k. ; dl.....
! ... COT✓MONWEALT14 OF MASSACHUSETTS e:• J(oo'17
Board of Health, F1f^"1Y A40it%%a MA.
d ..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
w"I
Permission is hereby granted to; Construct( ) Repair(,, `) UpgradeP.- Abandon( ) an individual sewage disposal system
S ro
r,. ��
at _( ' 0 t a" ` as described in the application for
Disposal System Construction Permit No. Al �;m/ P , dated /6 s`e /m
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
a •el ,y
Form 1255 aov. 5186 A.M. SWMn Co. Chvestm MA Date A-1,16,Pr°ice —Board of Health
r a W