HomeMy WebLinkAboutApp-Permit-ComploianceoN�L�I%-015 �5
f3LUTiz-2o-Ooi��B �1 lam,
No. - t Fee
of_ a (7 COTS NIONWEALTII OF MASSACHUSETTS -R .
Board (f Health, 1 GlX' MQVAki- MA. �C-p 19 2019
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION h .R�IT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ❑ Complete System ❑ Individual Components
Location 'C m.
1x-
Owner's Name4 Sfj,(-)
Map/Parcel#
e 1
Address %y 6 1te -
Lot#
Telephone#
Installer's Name R /'N
B
Designer's Nam I VdO
Address 2�, /P" G
//
sQD. Tvd'
Address A G
Telephone# ,i'" ,� c e -(y f 2l
Telephoner!
Type of Building &!D,4eA)6P Lot Size
d� yysq. ft.
Dwelling -No. of Bedrooms �'% /N -)Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
other rixtu'es
Design Flow (min% required) fLl'l� gpd Calculated design flow s f Design flow provided _� 5C gpd
Plan: Date / � Number of sheets _ Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION Or REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned ag/ees to inst Cyhe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree: [o t to p ac !!system in operation until a Certificate of om liance has been issued by the Board of Health.
Signed Date
No. / t b`'y 'bl) t• ah, B�".fs CCL d6576
,?7s.+t'
COMMONWEALTH OF MASSACHUSETTSIq�"
Board ofHenhh, "ri'izimt o1?t) MA
CERTIFICATE OF COMPLIANCE r `_ g��go)(l9
Description of Work: ❑ Individual Component(s) ❑ Complete System �*
The uncIT-signed hereby certify that the Sewage y
isposal System; Constructed ( ), Repaired ( ), Upgraded (__ Abandoned ( )
at I t 44// , X4rvz,
has been installed in accordance with the pi -ml si ns of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. !c( m
f ,daApproved Design Flow'*, ° 4� (gpd)
0
Installer !� 04"07 -r1" i a( "
ry ./
Designer•�24 •) Inspector: ttt
Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
'11No. )%•^'t�1,9�t6:: � e�.,���; (�`,�'?@�(.��tll At t"�t),��;�l��'.�a(��f 1t��4.1 FEE tom' "'', 7o
COMMONWEALTH Of MASSACHUSETTS
d
Board of Health, I/ --t') m o (.A'P"`) $ , M.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission isherebygrantedto;Construct( ) Repair( ) Upgrade(- ') Abandon()anindividual sewage disposal system
r
at f `s' r °`� .-01 �< as described in the application for
Disposal System Construction Permit No.1'-/`,),1`/ dated c3/
Provided: Construction shall be completed within three years of the date of this,,permit. All local conditions nutst be met.
Form 1255 Rev. 5196 A.M. Sulkln Co. ChadestuR 611 Date ,. ,�d/, `R'`✓`�` "+ Board of Health t<-'
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