HomeMy WebLinkAboutApp-Permit-ComplianceNo. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH ;",1" 5 E CU
CIO, LE
4.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( k4Upgrade ( ) Abandon ( ) .ecomplete System ❑ Individual Components
S �
Location
3 Map/Parcel #
Lot #
%� _
�D� r Installer's ame /yL
Address
of -3
Telephone #
� O ner's Name
..�..g¢...•A�.:.
Address
Telephpne #
/ eA s��ner s IV ame
Address
SosR '-7-7) — _62,9 3
Telephone #
Type of Building:
Dwelling — No. of Bedrooms
Other — Type of Building No. of persons
Other fixtures
Lot Size /67.4f? i a Sq. feet
Garbage Grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) ;R a. D gpd Calculated design flow 3 r/ gpd Design flow provided 3 7gpd
Plan: Date 9!±!:&e'10 - O g Number of sheets —� Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator . ,fir_ - Date of E
DESCRY IPTIO^^N OF REPAIRS OR ALTERATIONS
A_, -0 .1 r-. / V 1 -7 c0i7 % J On .. .
ffi
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further Tees not place system in operation until a Certificate of Compliance has been issued by the Board -of Health.
Signed Date d
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
vz�•®�,�•--- BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 2f<omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (_ Upgraded ( ), Abandoned ( )
by
at / 6:> -
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated F " ' l3 Approved Design Flow 3 159'/ (gpd)
Installer
Designer: � u�1+� L-fii�l Inspectorlty Date 1&10
75
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. THE COMMONWEALTH OF MASSACHUSETTS
a•v�<` BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted, to Construct ( ) Rep Ir(� Up,grade ( ) Abandon ( ) an individual sewage
disposal system at /G d9yu -r z.,a-.p... L -es as described
in the application for Disposal System Construction Permit No. S�6 dated 0'
f" -01V
Provided: Construction shall be completed within +-.e `� of the date of this permit. 1 cal conditions must be met.
Date ^��7 c� Board of Health Lee/ 4w�_O_
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBSB WARRENT' PUBLISHERS - BOSTON