HomeMy WebLinkAboutApp-Permit-ComplianceNo. THE COMMONWEALTH OF MASSACHUSETTS FEE 7v
BOARD OF HEALTH��
OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair (k Upgrade ( ) Abandon ( ) - WComplete System ❑ Individual Components
71 1/ -4-:1
Map/Parcel #
Address
Telephone #
Type of Building: �Gelq le A&21, 7u
Dwelling — No. of Bedrooms
Other — Type of Building No. of persons
Other fixtures
_ ,.Owner's Name
Address
C ph6ne #
SF� ^ (��,` C- Designer's M;
Vp l��I� r
Telephone #
Lot Size Sq. feet
Garbage Grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required),? 3o gpd Calculated design flow 333 gpd Design flow provided -3 3 gpd
Plan: Date Number of sheets _� Revision Date /Vo^-, 2
Title r
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator 10/3 C Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS�f4�A
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by
the Board of Health.
Signed / Date d ^b J
Inspections 4-2- 2 d' f
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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No.� THP COMMONWEALTH OF MASSACHUSETTS EE
dRiL 0 BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE /
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ),Repaired, Upgraded( ), Abandoned ( )
by: 611 Fre U S4,,,4 -A/4 � l✓l t � �yv t'
at -7( (f' M-4� , LA -L --
has been installed in accordance withthy� )visions of 310 CMR 15.00 (Title 5) and the approved design la as -built
plans relating to application No �jt� dated�� +�� 0-3 . Approved Design Flow (gpd)
Installer d v� -� C( J�'-I✓1 t ^t i J-C✓v t e-2 �vG � (easE
N
Designer: 9e- C tvVi Inspecto �' . Date 6 ��-NowFxPrleE
The issuance of this certificate shall not be construed a guar ntee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
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No. + -3 THEr(MMONWEALTH OF MASSACHUSETTS FEE
T�Y/V'd BOARD OF HEALTH l/
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair (x) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at -'7e dll LAC, V f - L #4, -Lt as described
in the application for Disposal System Construction Permit No. dated &- J4 -
kk,Provided: Construction shall be completed within tlmee s of the date of this permib All local conditions w4st be met.
Date `l1 Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON -