HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1504pc-1(04svg &LD-nz-1 "7 -00 0 S [a FEE � 53 4 0
A CC, 1-7 COMMONWEALTH OF MASSACHUSETTS
WBoard of Health,T ter/• MA.
2 APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location x f vs
Owner's Name
Map/Parcel#_f"
Address i o
Lot#
Telephone#
Installer's Nam
Designer's Name��
AddressAddress
R'�•e -57
Telephone# O _ -7.i_- PA�ZJ_
Telephone#
Type of Building =Lf '��� � it �f/ Lot Size • /�.�G sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided /`� y9 gpd
Plan: Date T�T�6' Number of sheets Revision Date'�Sl/�
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONSsrG r �-7`,r, .����, / 3 t1® f /<% ;Ka w'i .
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 ace the system in o eration until a Certificate of Compliance has been issued by the Board of Health.
Signed - Date &! l6'
Inspections
No. �C�C. ^�(Q-Q� FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE �� � `�� V4
QV_ A
Description of Work: LlIndividual Component(s) ®'Complete System
`t4
The undersigned reby certify that the Sewage Disposal System; Constructed ( ), Repaired (/.�pgraded ( ), Abandoned ( )
by: / ;7 �c'..s, s_ CO semc &W / CSS
at % —" r C •r i 7 Fca��'?
has been installed 'In accordance with th(Lprovisions of 3d0 CMR 15.00 (Title 5) and the{oved design plans/as-built plans relating to
application No.dated Y—,2 V <'(�. Approved Design Flow --s (gpd)
Installer �t�=
Designer: Inspector: Date:
The issuance of this permit X11 not be construed as a guarantee that the system will function as designed.
0,7,1V
No. I�aNDC-lb-62�V we COD, 5c-pnc SE01(5 FEE
17 COMMONWFALT14 OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( Upgrade ( ) Abandon ( ) an individual sewage disposal system
at / rrizC-e,-,- as described in the application for
Disposal System Construction Permit No/
b -2 , dated 9 /�
Provided: Construction shall be completed within three years of the date of this per l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -(Board of Health ='a
4�
No. f$0WPC- [6--62-0$ &UDTIZ-17 -00 0 S 10 FEE � 5 ..40
-7 COMMONWEALTH OF MASSACHUSETTS
Board of Health,T cry• MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 272f os
Owner's Name d '
Map/Parcel#
Address i d
Lot#
Telephone# �•`�_y�7
Installer's Nam.
Designer's Name
AddressAddress
3S d ra*� .�.-
-79,
Telephone# ® _ 7-7.j , '8�,f—
Telephone# d�I_'�✓�?_ ff�-
Type of BuildingLot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
/!mac sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided �3 *!�r gpd
Plan: Date 72ZI ' Number of sheets f Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTE TIONS•I
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 ace the system m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed - Date res
s
Inspections
p;'3V
No. t✓� C "�(n��Z-Q� FEE 35.00
COMMONWEALT14 OF MASSACHUSETTS C&*/(0Z_S
Board of Health, ®��eT`fi MA. At
CERTIFICATE Of COMPLIANCE�
Description of Work: LlYd
Individual Component(s) 'Complete System
The undersigned reby certify that the Sewage Disposal System; Constructed ( ), Repaired (l.Upgraded ( ), Abandoned ( )
by: c''�. �, s. Cob 5 G e2V l C
at Cal ?r
has been installed j' accordance with the -provisions of 3d0 CMR 15.00 (Title 5) and the oved design plans/as-built plans relating to
application No. 6 ,.1 ! dated�-.2
-��q /(�. Approved Design Flow --� (gpd)
Installer���r
Designer: g j 67 Inspector: Date:
The issuance of this permit s call not be construed as a guarantee that the system will function as designed.
No. I���DC-ib-.(�Z�� Gp�E COD 5GPT)C SE)OVICS FEE ST 100
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon ( ) an individual sewage disposal system
at ev'p, s / as described in the application for
Disposal System Construction Permit No/ lol dated 9k
Provided: Construction shall be completed within three years of the date of this per . l )local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date � -/-(,Board of Health ��/
T r� •