218 Septic Application Permit & Compliance 2006 Appbcatic
FEE
COMMONWEALTH OF MASSACHUSETTS 'i (
RoaraoyHratrn, /01)//T// Tar.,wn.
APPLICAT➢ON FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
or a Permit to Construct) RepairX Cpgradef Abandon( ) - /Complete System O Individual Components
Location _7--65r i)ii R/a/z//F/2
Owner's Name GfF // /)4 A'Pt
T P 3
Map/Patcei#2/6)
(O( rs .1-2,-/mow ?IO
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Andress
TelephoncN
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Lot# /tier
Installer's Name
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a) (10 0/7
Designers Name km L/ f)/6J cy/f/2 LS i f%
Address -
�
.Address
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LTclephoneg
p
<// � 217. 760 r I t4O-.
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T/
' L3_$ 7 '%J S
Type ofBuilding .(5//7 AJT/I2( NOW')C Lot Sue Ca / 5//Xis q�1c
Dwelling Nr. of Bedro 3 j%4/007-/ ,U0 Di 9f/a5/t iJA/% Garbage grinder WO
Other-Type of Building 5-;VG CE /7,4 h9;14/ No of persons /O Showers (L„Cafeteria (4)G
Other Fixtures 7G/(L 841T
Design Flow (min.re[q/uired)//U Al 3 gpd Calculated design flow _YJ ) Design flow provided 33/
PI Date�n / /r/ (7h0 Numberof sheets
gpd
Rr r+on Date /(/)/Li
Title 57177 ?</r/T/'// /7/=,/ L-' r g T 8/2/1 fl f? 0.2/8 GOCCS 4-l-/'/9/7Gw �0
Description of Soil(s) f� //7i//(Aii/)
Soil Evaluator Form No. //
DESCRIPTION OF REPAIRS OR ALTERATIONS
pr.7f/0n 44-aci //G V
Name of Soil Etahiamr �S a c n valuation ��'�
(S/Th(U/“IgbFS/6 4,1 c'CI LS/
•
rcr fib, sr/)77( .Sys-/ / /ZP670s/942
(414 /s Q
The undersigned agrees to instal the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to/rot to place the sys min operation until a Certificate of omplance has been issued by the Board of Health.
Signed ?� ,�[-..% i.U'r/>T•M'C.Date 9/ 7/oc-
Inspections
COMMONWEALTH OF MASSACHUSETTS
Board of Health, /J1/42-71H "1! /oiJ MA.
CEIIIIFIC: " _ OF COMPLIANCE
Description of Work ❑Individual Components) beComplete System
The undcyg ed 1 reby ce tify that the Sewage Disposal System; Constructed ( ),Repaired O Upgraded (rj,A andoned ( )
b.-: 7 / r,: / f ' 7b✓esi sr A-ra-ri=/ Lt-0 1'/ — 9Ge7;
at
has heen installed in ar ordain e with the pros isions of 310 CMR 15.00 (Title 5) and the apprrncd design l fans/asbt It plans relating to
application Co ; /% dater r a Appnned Design Flow vi / (gpd)
Imtallev-t°'•
FEE -xJ. -,''
%6?
Designer:
The issuance of
It-
lnspecwr: / 4 ):)-% :&V (a*s<C43 Date.
permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, / // /e/-91 y2 wL
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(
at - i ) t .• ss L »7i-
Disposal System Construction Permit No. '✓`! '�� , dated/'l l/s /U/,(J
Provided: Construction shall be completed wityin th)ee years of the date of this perm'. ; All locall�r dtiicieR+nwsi be met.
For 1255 Rev 5.96 A,M.6ulpn Co.Boston.MA Date '1/ t; t'o'rt Board of Health
/ t
FEE ( 56./6
s ilt .
Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
ea, OjZ2'4n , 7
2/2716a# Street
?2ontlramizta(c, 716,4 01060
%C. 413-587-1214
lax 41S-517-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE DESIGNING ENGINEER AND THE
SYSTEM INSTALLER
DESIGNER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code: Title V,Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage,Section 15.021 (3),the Designer and the Installer of a system are
required to sign this form as a condition for issuance of a Board of Health Certificate of Compliance for the
onsite septic system
This is to certify that the onsite sewage disposal system that I designed as:
at o?/B COL-if /Y/!t/51/701-0 la on AVO CO
(Address) (Date)
new construction
XI repair(existing system)
DWCP number 7!Y)(o - 17
has been constructed in compliance with 310 CMR 15.00, and all local requirements.Any changes to the
original approved plans have been reflected on an as-built plan that has been submitted to the Board of Health.
/4 s S1E/Z-074 PE
Dwi=er's me) (Address)
/IV V/66
Designer's signature) (Date)
46G,o%iid i2? /4cye6 4-/4
INSTALLER SIGN-OFF
Thus is to certify that the onsite sewage disposal system that I installed on /CV V G 47
(Date)
at the above-referenced address has been constructed in compliance with 310 CMR 15.00,and with the approved
plan and all local requirements.
Tom- &tz--, 5(,&-P sr eSTA&97
.3-0 HA/ (orroti/ /3/4217-titc0
(Print Instal er's name) (Address)
(Installer'ssigature) /d/p V° 6 (Date)
NOTE:This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system Rather,the plan and installation are in compliance with all applicable rules and regulations as are
in effect at the time of plan submittal