HomeMy WebLinkAboutApp-Permit-Compliance- No. Dc-?Ow613 _P 5 er r
oaf 07 C®MM ONWALTIT OF MASSACHUSETTS
/V . DS -5- Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI
Application for a Permit to Construct( ) Repair( ) Upgradetvy-Abandon( ) - ❑ Complete System
FEE
FEB 2 6 2020
PERMIT
HEALTH DEPT.
tdividual Components
Location Ljgq nll'-e (sj+1%trolovt 4.4a
Owner's Name 5omook ReeJ Ly�(}
Map/Parcel# 1 /72,
Address
Lot#
Telephone# t(/�
Installer's Name Roto r' -i- 6 uvr
Designer's Name bail KtVdt"
Address 363
Address PO Boy 1163 Dennlj
Telephone# ,5"60 LiS2-6.5-30
Telephone#
Type of Building K12 1'G t 1 ((t M A9o," tt%ttil Lot Size j_%_3 t' sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures 2
Design Flow (min. required) 53Y gpd Calculated design flow
Plan: Date Number of sheets ri
Title LtqLA S 7-- I
Description of Soil (s) _
Soil Evaluator Form No,
M&O P,
Design flow provided T gpd
Revision Date
Name of Soil Evaluator WcLellcgn Date of Evaluation
DESCRIPTION OFREPAIRS ORALTERATIONS Hi (A '"'1 /&eeG/ J—
�rA6l
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed U_- Date
L.
Inspections
No. 1,1-.}t.{,.ii(20.,w.,;6_ - a�a„ t .,..a FEE fit, <Fl
COMMONWEALTH ®F M ASSAC14USETTS"
Board of Health, °/xusv(Y4o71-t MA, Via„ a
CERTIFICATE Of COMPLIANCE fl�
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,xis), Abandoned ( )
by. ra` ..o. f-,. <,
at S„t ;.{ u.i f( , a:a�• ,4 r0 _. F, >.( .. w t` ..✓, , .,..,%8.
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. 9 t ” i a ``, , dated �- P l % 1?. d;" Approved Design Flow (gpd)
V2,
Installer * t
)t'�sx^^"t' V�, t@suw dd
t.�: D ..� n", . ,a „ ,. a Date:
Designer: ��,t,i; 1«),w,ax�`- ,��arz�s'aInspector a•M,°r ,� -°
The issuance of this permit shall not be construed as a guarantee that tete system will function as designed.
.r
No. ,0�. t. FEE
COMMONWEALTH
OF MASSACHUSETTS
Board of Health, 41842} 07 -dr- MA.
n
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(`) Abandon( ) an individual sewage disposal system
at { ( ` t 't ° -+a, as described in the application for
Disposal System Construction Permit No.r t i dated''
r
Provided: Construction shall be completed within three years of the date of this permit All local conditions must be met.
Form 1255 Rev. 5/96 0.M, Sul in Co. Ctaddoee, MA Date= �1, Board of Health