HomeMy WebLinkAboutApp-Permit-ComplianceNo.
COMMONWEALTH Of MASSACHUSETTS
v ARMOUTH HEALTH DEPT.
Board of Help 6 ROUTE 28 , MA.
APPLICATION FOR DI S"? STRUCTION PERMI1
FEE
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Names
Map/Parcel# S / / 3
Address f�
Lot#
Telephone#
Installer's Name t e f j
Designer's Name
G 04.
Address / KI
Address / Z 51T
Telephone# Ll 3 p„ 0.0/z-
Telephone# ?d 71 - % Z -
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms S Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 310 gpd Calculated design flow Design flow provided ��� gpd
Plan: Date r°- 2-7-01 Number of sheets / Revision'Date
Titfe ,� /
Description of Soil (s) del �/ " jj ��//
Soit Evaluator Form No. Name of Soil Evaluator ��ewz,— , Al i.1 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -va ZX // dl <a A f
1 S-tV-C, a 6v, -rA--j ic- 1�0) Ko hS-e✓�z�-. YAs as
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to acethhrsyste operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 4$ -
Inspections
No. FEE. G`lV
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, MA.
C ERTIFICATV Of COMPLIANCE n
Description of Work: U Individual Component(s) ®`Complete System
The undersigned hereb certify that the S w1age Disposal System; Constructed ( )J,rRerp�aire�dl (I Upgraded ( ), Abandoned ( )
by: Mia e, /UoXe Ti 11.G r��Te JCE ISI �i/i
has been installed in accordan with the rovisi ns of 3 0 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No. .Z `/7 S , dated pproved Design Flow (gpd)
Installer r /
Designer: F� 4n ' / Inspector: Z, Date:
f
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ri+ < / J f .tee f -FEE
COMMONWEALTH OF MASSAC14USETTS V7
:Z 74o
Board of Health, �'I" ; AM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ') Upgrade ('� Abandon( ) an individual sewage disposal system
atas described in the application for
Disposal System Construction Permit No. 02 17�5dated��
Provided: Construction shall be completed within thTer-7VMV*of the date of this pe it. 1 local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dated of Health