HomeMy WebLinkAboutApp-Permit-ComplianceNo. B oac-Zo- 7.kSO e7W-r E- 2-0-0044 cj�
COMMONWEALTH /OF MASSACHUSETTS
SETTS
Board (?f Health, MA.
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X61161 00,
FEE
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PER �I� 2 9 2020
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - O Complete System ❑ Indi4udkk
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Location
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Owner's�f.i/�I
Map/Parcel#
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Address L-37 T5,�T P-A..I-M Pd.
Lot#
Telephone#
Installer's Name
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Designer's Name
Address � 2 fy.oh pttrP S YATl-1- r N A t s
Address���
Telephone# Ci
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Tclephonetk S'° P F-
Type of Building 4 e---- Lot Size 1574W4� sq. ft.
Dwelling - No. of Bedrooms /OGarbage grinder ( )
Other - Type of Building
Other• Fixu r'es
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required)q gpd Calculated design flow y✓`S 0 Design flow provided gpd
Plan: Date —6--27— ,/ Number of sheets Revision Date
Title -07
Description of Soil(s) Gry /d?S /OZm
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Soil Evaluator Form No. /38%I Name of Soil );valuator�Z/Cy Date of Evaluation
DESCRIPTION OF REPAIRS
The undersigned. •ees to' the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of to ace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
No. 99 COMMONWEALTH Of MASSAC11UShqTS FEE
Board ofHeallh, MA.
CERTIFICATE ADL COMP.11ANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System y
The undersigned hereby certify that the Sewage Disposal System; Constructed `QRepaired O, Upgraded O, Abandoned ( )
by: P t�> 4T -
at d
has been installed in accordance with the p'oviston f 310 CMR 15.00 (Tide 5) and t approved design plans/as-built plans relating to
application No. - (, °"�- dated t e)```'t•'' Approved Design Flow (gpd)
Installer t'm'P 16-;P!%t}111, F0 k2 T" ('S 11.. co 7'RWC Ti C±M
Designer:,i OtP-1 �� ����- Inspector: 1 Date: s`
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. d / �
No. '
@,..%1'J@*i' @.� .�.. >( ....?-'sL � � \ i i FEE tYI)
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99 COMMONWEALTH OF MASSACHUSETTS
Board of Health, V,"14194/ MA.
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DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(') Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
b i�( i;#
° at `' ` �"�' 1�'--1 6 '�`I<-,i°) ` " t a as described in the application for
Disposal System Construction Permit No ) dated "
Provided: Construction shall be completed Within three years of the date ofthispermit. All local conditions Hurst be met.
Wee 1255 Rev. 5196 A.M. SuIAIn Co. Cteftmvn,MA Date al al4l�" ✓✓" 4' Board of Health.=`t-'•4
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