HomeMy WebLinkAboutApp-Permit-ComplianceFEE No. ��`�: C _ vvc��I (�`(7r00
7
,06 "C -(G -02-0-L- COMMONWEALTH OF MASS CHUSETTS cOz qq
W r 7
Board of Health, T d UI , MA. ,2 ��XK`5
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT
A T
plication for a Permit to Construct( ) Repair( ) Upgrade Abandon( ❑ Complete System Zdividual Components
Location UC,. 9 rv- a Owner's Name f'f n"7j0I.3T�
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Lot Size (OZ (Z)(— sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) y q c) gpd Calculated design flow O Design flow provided
Plan: Date 71 la -. Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form Nc
AIR Aoc-1-oa s —Lo7A
Name of Soil EvaluatorAA-A `Vnh2kbj-'O- Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS (nO a gy:cn Al UA A M
1 . I 1\,,,,97 ^r c.,-_ ,.n —
gpd
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 pl system in operation until a Certificate of Cogipliance has been issued by the Board of Health.
Signed L /�=:�F � Date
o
Inspections 1-2-1(g &j 7e,0
)AS (
_._..._. �No. u�!'�U�f�� FEE �. 00
COMMONWEALT14 Of MASSACHUSETTS
`, c4 f co l, �, G Z DU�1 7
Board of Health, y.� 9-ffl0-dZX , MA.
CERTIFICATE Of COMPLIANCE _
Description of Work: � individual Components) ❑ Complete System -D,
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ), UpgradedAbandoned ( )
by: P10 6e r' -i 8. O l) (- C C), T� NG ,
has been installed in accordance with the provisions of 3 0 CMR 15.00 (Title 5)and thea roved design plans/as-built plans relating to
application No. datedApproved Design Flo (gpd)
Installer C- 41Z (S . O pH e V `G-'.. �� �. lc /
Designer: �a-Y�55 �? ii (N , Inspector: , Date:
The issuance of this Permit shall not be oa
cnstrued as a guarantee at the. system will function as designed
.,��or„��.; �., oc�� .. ,. _ ..
No. e O 4-b ” t (o -02-0 2- r? . 16 : 0 v (e- CC) r FEE
- COMMONWEALTH Of MASSACHUSETTS . 000 7 q 9
Board of Health, y6M QJT 4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; nConstruct( ) Repair( ) Upgrade,(-< Abandon ( ) an individual sewage disposal system
/
at / '? 9 EJ U 4e (� c;C,IL R_ as described in the application for
Disposal System Construction Permit No. 4 dated 9. �2r -
Provided: Construction shall be completed within His the date of this pertqit: 1 local conditions must be met.
I,
Map/Parcel#
is
Address L,(XX
C� t_J�()N R
Lot#
Telephone# _
--- 5G 4-1
Installer's Name
06e T T 8 t ® v \ 5� C-
Designer's Name
• vzr- c4.oe.
Address'
(l' g(o Lj_r
AddressPC) RD)(
3 N �
Telephone#d
3 -
Telephone# r
Ll C) L4 g
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Lot Size (OZ (Z)(— sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) y q c) gpd Calculated design flow O Design flow provided
Plan: Date 71 la -. Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form Nc
AIR Aoc-1-oa s —Lo7A
Name of Soil EvaluatorAA-A `Vnh2kbj-'O- Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS (nO a gy:cn Al UA A M
1 . I 1\,,,,97 ^r c.,-_ ,.n —
gpd
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 pl system in operation until a Certificate of Cogipliance has been issued by the Board of Health.
Signed L /�=:�F � Date
o
Inspections 1-2-1(g &j 7e,0
)AS (
_._..._. �No. u�!'�U�f�� FEE �. 00
COMMONWEALT14 Of MASSACHUSETTS
`, c4 f co l, �, G Z DU�1 7
Board of Health, y.� 9-ffl0-dZX , MA.
CERTIFICATE Of COMPLIANCE _
Description of Work: � individual Components) ❑ Complete System -D,
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ), UpgradedAbandoned ( )
by: P10 6e r' -i 8. O l) (- C C), T� NG ,
has been installed in accordance with the provisions of 3 0 CMR 15.00 (Title 5)and thea roved design plans/as-built plans relating to
application No. datedApproved Design Flo (gpd)
Installer C- 41Z (S . O pH e V `G-'.. �� �. lc /
Designer: �a-Y�55 �? ii (N , Inspector: , Date:
The issuance of this Permit shall not be oa
cnstrued as a guarantee at the. system will function as designed
.,��or„��.; �., oc�� .. ,. _ ..
No. e O 4-b ” t (o -02-0 2- r? . 16 : 0 v (e- CC) r FEE
- COMMONWEALTH Of MASSACHUSETTS . 000 7 q 9
Board of Health, y6M QJT 4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; nConstruct( ) Repair( ) Upgrade,(-< Abandon ( ) an individual sewage disposal system
/
at / '? 9 EJ U 4e (� c;C,IL R_ as described in the application for
Disposal System Construction Permit No. 4 dated 9. �2r -
Provided: Construction shall be completed within His the date of this pertqit: 1 local conditions must be met.