HomeMy WebLinkAboutApp-Permit-ComplianceNO. k/d►t�C THE COMMONWEALTH OF MASSACHUSETTS
FEE $5y-00 -
BOARD OF HEALTH C I U U
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- , W,R TfO FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair ( ) Upgrade (>c* Abandon( ) - Complete System ❑ Individual Components
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Map/Parcel #
Lot #
S�talleI s Name
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Owner's Name
Address
Tele hone #
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7100 3(
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Telephone #
Type of Building: J'�/i/��� �iL�' Lot Size XV .�'�' Sq. feet
Dwelling — No. of Bedrooms Garbage Grinder..(—)s
Other — Type of Building No. of persons %-% Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (min. required) //U gpd Calculated design flow S�gpd Design flow provided �7�gpd
Plan: Date 12-/2_46 Number of sheets / Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator ��/� �� Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS /i/C )C4(1�K , 5ALL1,S C --A4 ?5
The undersigned agrees to ins a above described Individual Sewage Disposal System icordante with rovisions of
TITLE 5 and further agrees p c the s in operation until a Certificate of Compliance h ;issued by th of Health.
m
Si Date 1 CF''
Inspectio o.
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/
NO. WAIXi' �7 THE COMMONWEALTH OF MASSACH SETTS, E 00 ^
n / li�?� �f
'BOARD OF HEALTH 6 �11',z7 � jaU"Z.
3. �2.�_
CERTIFICATE .OF COMPLIANCE / eri el PL- 1-7— 60k_7r).
Description of Work: ❑ Individual Component(s) Complete System OIL -
Ito
The,undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( UVgradedtsndoned (
by:.
>� Jrir�';Lh C'ug 5�turtil w� J, s�i�
at 93 M
has been installed in accordance with the ovisions of 310 CM 15.00 Title 5) and`the approyed design la as -built
plans relating to application No.datedApproved Desi-gn Flow —(gpd)
Installer J �Gv�c t i �>Ykl E
.-�
Desi ner: C -4Q c1.1 lc -N6
g � Inspector Date
The issuance of this certificate shall not be construed as..a VEP
that the system will function as designed.
NCE ®E
FORM 3 - CERTIFICATE OF COMPLIAP APPROVED FORM 5/96
No. fJd!.c-"-t7—iHE COMMONWEALTH OF MASSACHUSETTS FEE `,00
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�,,;jGl BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is -hereby granted to Construct ( ) RepairUpgrade ( )Abandon ( ) an individual sewage
disposal system at _ 30 42w A 0 as described
in the application for DisporI-System Construction Permit No. 7 �� dated��i'��% �i� 7
Provided: Construction shad 1.1ie completed within�of the date of this permit: Al conditions must I met.
Date 7 Board of Health
FORM,2 - DSCP !l..DEQ APPROVED FORM 5/96
JFORM 1255 (REV 5/6 .h&W HOBBSB WARREN TM PUBLIS RS - BOSTON -
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