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Home My WebLink AboutApp-Permit-Compliance 130711Z 21-ooSSZ1 No. �A Z1 FEE• . (_DS(,Q COMMONWEALTH Or MASSACHUSETTS • Board of Health, \I occ rti'l >Lkh ,MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade{ Abandon( ) - komplete System 0 Individual Components Location 5 f ',4 rex 5 7— Owner's Name 0,. 4.4,1' Map/Parcel# 2 Z — /c ) Address Q e�jl/ �Q( E i ll/avi/T Lot# Telephone# .S27 -b/'1- 3j� Installer's Name DAG-, 7- �,lvST/LUG A1 Designer's Name !�/f/f�t/e/L / & *i 5 Address L Z-.pi u05 711 D6AA,i5 Address?© e (/ fat) u L -4,-M/1 Telephone# . d7_ 4/3 Z-/6 9,5 Telephone# Lcb -360-3.51 I Type of Building r-)4-01-L1"1 Lot Size sq.ft. Dwelling-No.of Bedrooms ` Garbage grinder( ) Other-Type of Building No.of persons Showers( ),Cafeteria( ) Other Fixtures Design Flow(min.required) _.33'd gpd Calculated design flow U Design flow provided .ado gpd Plan: Date /2-L/-ZGd Number of sheets J Revision Date / � Zi Title V SF prle Description ofSoil(s) /4/4.40 i ''�, Soil Evaluator Form No. Name of Soil Evaluator 2100,.tl 94C-kbate of Evaluation /2 ^ DESCRIPTION OF REPAIRS OR ALTERATIONS 0,-/..C-105?!'T 4070 pey.4/ /1"1/tr �� 16 --//'��C - 4' 414.1e ui �• 1.t rvCt-itef'tz(1.% //A, S. Nc The undersigned agre to insrlthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to no o pleb the system in operation until a Certificate of Compliance has been issued by die Board of Health. Signed Date /Q /021 Inspections No. S.il J \}r 2 '. FEE COMMONWEALTH or MASSACHUSETTS .s Board of Health, y(3.rrnQ�.A-4(1 ,MA. }_o��,` 147 `,"'' CERTIFICATE OF COMPLIANCE Description of Work: 0 Individual Component(s) Complete System r The undersigned hereby certify[h t theS}ewage Disposal System; Constructed( ),Repaired( ),Upgraded k), (),Abandoned by �{ tr14,1111, at has been installed in accordance with the r visi sof 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to application No. 2-1-0510, date ri Z I . Approved Design Flow 330 (gpd) Installer Di I.}-cht^e4)-kc-- Designer: Inspector. � �� --��/ -� _ Date: ?7 7J � �2o,Z The issuance of this permit shall not be construed as a guarantee thaw -tem "=�S+ .'on as designed. No.Vf\ , 2_' I FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, �O,r ,MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permissioniois hereby granted to; Construct( ) Repair( ) Upgrade(XI Abandon( )an individual sewage disposal system at '7 INkTEQ- S� ., o� as described in the application for f Disposal System Construction Permit No. �-D ,dated 3/1 Provided: Construction shall be completed 'hin t'r'ee years of the date o is per • Allilo..r con.':ons must be met. Form 1255 Rev.556 AM.Sul&Co.WeinHA Date 3 11 711 Board of xea h //MI' %/;,,u�'