HomeMy WebLinkAboutApp-Permit-ComplianceNo. — rr•-c
COMMONWEALTT[ OF MASSAG-JIUSETTS
Board q Health, N_W (YV x- 11/1"1.
i
APPLICATION FOIA DISPOSAL SYSTEM CONS -RUCTION PERMIT
Application for a Permit to Construct( ) Repair/) Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
Location .(-\ "VC?
\`C,( Owner's Name )e
G - -1(020
Map/Parcel# OZ"LInc-as
- Address-Lkn .-
Lot#
Telephonelf
Installer's Name9
P Designer's Name
Address2 c -
M �_ �L Addres4 •'
Telephone# �"-(L _(7�
Telephonelt
Type of Buildingky:��\R.'Cy k A Lot Size 0�4-\ C.\ fe sq, ft.
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. or persons Showers ( ), Cafeteria ( )
Other ristttres
Design Flow (m'n. req tired) � `) gpd Calculated design flow �``) Design flow provided �)3G gpd
Phan: Date �� �� Z.� Number of sheets 2 Revision Date
Title,
Description of Soil(s)t)-S'. `C`�c-.m. �5[ t�•• t'�1 `Qc
Soil Evaluator Form No. Name of Soil Evaluator
r
Date of Evaluation
St,v�
[ The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
[fS further agrees to not to place the system in operation until a Certificate of Cot'`�liance has been issued by the Board of Health.
Signed �✓ �""--7/"� Date
No. 9,r•2Z ' Z`-'5
COMMON1YLf\ETI Of N[S�S�ZIC1IUa1ITTS
Board of HealthL C (�f 1�, ib1A.
FEE _
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) XXoniplete System /
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (a/j, Upgraded ( ), Abandoned ( )
by:J C\
has been installed in accordance with the pr evasions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.ZZ ^at a , dated Z t - Approved Design Plow 33 (gpd)
Installer r (-f\ J v- C
Designer: �� 50 �'j Inspector: IJ• i�•�`�'-GGZ I, 7te.—ILL`ZZ-
The issuance of this permit shill not be construed as a guarantee that the system wirl function as designed..
,_a,._-• .�..- arc
COMMONW11--ALT-1-1 Of MASSACIIUSLI-ITS �=
Board cfHea1th,\1V-'`(Y'yir-,k-MA.
DISPOSAL SYSTEM CONSTRUCTION PI:RMI1
Permission is hereby granted to; Construct( ) Repair(-v/'
Upgrade( ) Abandon( ) an individual sewage disposal system
atc'0. 1 as described in the application for
Disposal System Construction uction Permit No. ` ` QS , dated
Provided: Construction shall be completed within three-yeays of the date of this permit. All local conditions must be met.
Fore,1255 Rev.519e A.td.Smkmco.ChadeV,MA Date -•z 1 `""`' L Board of Health "jt'�`-;� f # <"J -I. �'`-"`t•-'"`