HomeMy WebLinkAboutApp-Permit-ComplianceNo. - -bvr 4 *.1 P/v- / FEE
COMMONWEALTH OF MASSACHUSETTS
060�41
%I> Board of Health, YA021A^
UTH HEALTH D,PT.
m�- APPLICATION FOR DISPOW1VM9P1R-MMqVJCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( sl"'Abandon( ) - ❑ Complete System ❑ Individual Components
Location IT
Owner's Name (b
Map/Parcel# 1147
Address
Lot#
Telephone#
Installer's Name � ,� -
Designer's Name C.Ore- i_ -L.. v
Address
Address
Telephone#,ZqtA_ a
Telephone#p �,
Type of BuildingLot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. reuired) gpd Calculated design flow
Plan: Date :LJ02— Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No
of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS Ne> -'J S_ A: E2
Design flow provided -'1'33 gpd
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
" further agrees to to_place the peration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 7Al' Z
-,inspections &"/4-'r? X Sd mPmotC/./ c&, S-r1�i," QA ydnG/" a q!. y7h-o F SC,4
w V - l Q� atad�-
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COMMONWAITH OF MASSAC14USETTS
Board of Health '�j r� �aFf ALA. 1/1(
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑ Complete System 12,001- �+ .
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (, Abandoned
by: `� V c t d1 r S c�`i
at IT�� %p a r.J L f R •d1s C_
has been installed in aCcordarLre with the provisions o 310 CMR 15.00 (Title 5) an approved design plans/as-built plans relating to
application No. `` dated -i � Approved Design Flow (gpd)
" InstallerWL.�\✓�C^�Uf'icr�J n
Designer Y`A E � , oV3 j I I,( Inspector: NXiz Date: _/
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
lFEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ..r% , MA.
DISPOSAL SYSTE 'l[ ONSTRUCTION PERMIT �
Permission is hereby granted to; Construct( ) Repair( ) Upgrade,( Abandon (. ) an individual sewage disposal/stem'
aty : t -�ato LA„d4-e— as described in the application for
Disposal System Construction Permit No. 02� dated %>`>` ZV2^
Provided: Construction shall be completed withialbx@ ars dl"fhe date of this permit. All local conditions st be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dateoard of health