HomeMy WebLinkAboutApp-Permit-ComplianceNo e✓y hr�C 4�Wt��
tuvi m -&-o 02_07
( cpf SIONWE-ALTII OF MASSACHUSETTS
Board ofHealth, yY�a2lY1Bl1T7d MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Rr_pail'(\ ) Upgrade( ) Abandon( - 0 Complete System
NOV MUM
UM
Components
Location rA 450L[_)Ns qcQ D
Owner's Name 6
e tccl
Map/Parcel#
Address v
,CwQcd
Lot#
Telephone# 5A
�� aQ---2)
Installer's Name,
Designer's Name S
t' /� 1. r `r V f
Address Vb NAD"x {IrAM10
Addressjo3 Ce
e}' ttraJ. S. P) and
Telephone# 4
i Telephone# S'
Type of Building Ql�;Vm"I 1ulk Lot Size / 90 9� 9, 1 sq. £t.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons -J Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. requiredy_ -�>
Plan: Date 10 /17 .1olJ
Title
Description of Soil(s)
—
Soil Evaluator Form No.
_gpd Calculated design flow
Number of sheets
, II
_ Name of Soil EvaluatorS�L'i
DESCRIPTION OF REPAIRS OR ALTERATIONS
J, k M 11. fl.,,, z r
Design flow provided 5 I gpd
Revision Date
Date of Evaluation lO%/-1119
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t¢�t try to place the s in opet� ration until a Certificatef Co liance has been issued by the Board of Health.
Signed 2 M--� \ Date
///aS f/ 7 -
No 'l..®1`'lll`d®NWEALll1t� ®$' 1'1i$49 Ji4C$fU49ETT�9�iP N�^•��FCE.tl}9
Board of Health, � A-i?,A -ll) epk MA. ��
CERTIFICATE OF COMPLIANCE
Description of Work:-^D\;jndividual Component(s) 0 Complete System - „c
The unders ned hereby 7-tify that the Sewage Disposal System, Constructed ( ), Repaired ( ),Upgraded ( ),Abandoned O
p* g S p
b it/ t , K th � r e' - 'C' Pp r
Y' e
at rl Fd,tMS ', P ,, A vete) ^ -.
has been installed in accordance with the provisions of„,,310 CMR 15,00 (Title 5) and the. approved design plans/as-built plans relating to
application No. S ^` " t""`dated l l •_°'^ .l'k," .Approved Design Flow .�; ��" (gpd)
v. p
Installer �"� '<"�-•�"°'"
Designer:we„t t
'T � Inspector `vate:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
,r
No
FEE „;y4 f`.. r
COMMONWEALTH OF MASSACHUSETTS
W. P
Board of Health, V(112W �YrA- •- MA.
DISK®SAL SYSTEM CONSTRUCTI®N PERMIT
Permission is hereby granted to;
at (.•ei � a q�'r
) Repair( ) Upgrade( ) Abandon(
Disposal System Construction Permit No. . e dated f
an individual sewage disposal system
_ as described in the application for
Provided: Construction shall be completed within three years of the date of this -permit. Alllocalconditions Hurst be met.
/." a° r t,J f day,
Form 7255 Rev. 5/96 A.M.SNNin Co. Chelk5lvNn,MA Date � ,+��: Board of Health
. c.
9J
, ✓ .ter ',,, +