HomeMy WebLinkAboutApp-Permit-Compliance3oWDCA i4o6e ►�6 y
No. FEE
9 a COMMONWEALTH OF MASSACHUSETTS N
Board of Health, Y&9%Y)DUT_)+ MA. ocr 3 0 2019
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
f ( / HEALTH L�I:P j',
Application for a Permit to Construct.( ) Repair(y0j Upgrade( ) Abandon - ❑ Complete System C93'ndividual C'omp`onents �"'�Y�`
Location kpb " , t i
Owner's Name -`
Map/Parcel# (os
Address
Lodt
Telephone#
Installer's Name5At ,,b YC (..
Designer's Name
Address �� CG..(_nwV"1�.�.'C� Nv,�Address
Telephone# y
Telephonclk
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other FIXLUreS
Design Flow (ruin. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
_gpd Calculated design flow
Number of sheets
OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
In
Design flow provided gpd
Revision Date
Date of Evaluation
Fin
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 ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ,�--. Date �,i`s 0� 2u 11.
Inspections
No (''`-'4"9 ��'t• <� .�. fiL Y+:e:.> 3 .... ,Ntt , r....<...�,•� FEl " ` CIO
t - COMMONWEALTH OF MASSACHUSETTS , � (' (`:0
Board of Health, Y a��! �ki (S C)'T 14-- MA.
II
CERTIFICATE OF COMPLIANCE
Description of Work: DT dividual Component(s) D Complete System ,.�•
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired S4, Upgraded ( ), Abandoned ( )
by: z.^ ( 4
at L,e %
has been installed in accordance with the prppovis ons of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. d I °"' e..� dated 1l ! 8- r t' Approved Design Flow (gpd)
Installer gar'"(^4 N`a 'r -A,0<,
Designer: '" Inspector .�t •``»t`,,:i_.=*+'.�e�r'•,v;�,l°� Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. r5 0 ('t ) �.. - �,`.'1 "`E �.I `".} i,.,w C JT R�) �. te'.. .�.,�1 r,.- t.r� G_ ti! v .-..� s �"'FEE
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, \%j.{A,� (1 i MA.
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DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gran ted to; Construct( ) Repair(') Upgrade( ) Abandon( ) an individual sewage disposal system
at
r
D' osal S stem Co str-uction Permit No ) ") "" � � - ' dated
Di
as described in the application for
y n. , <
Provided: Construction shall be completed within three years of the date of this permit. All local conditions mustbe met.
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Form 1256 Rev. 6196 A.M. Solkin Go. OladeWn,6tA Date .u"'' '� � . ``✓� Board of Health ;�'' t• `t'"'>` +' � �'�. .