HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,zo�
-7rz�r✓� io --3 10
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF b
FEE / V V
)W� 45szg
-
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade (Abandon ( ) - ❑ Complete System [:]Individual Components
Cy 6 Z 1%t
I Map/Parcel #
V Installer's �UVJNNam�e(�,
:z -X l P rC
A dress Telephone #
Type of Building: N<ve.6 .
Dwelling — No. of Bedrooms 3
Other — Type of Building No.
Other fixtures
/owner'sAddress
_ o Telephone #
Designer's Name
'73,P) ss
Telephone #
Lot Size 93,5-7/ Sq. feet
Garbage Grinder ( )
of persons Showers ( ), Cafeteria
Design Flow (min. required) 3 3cQ gpd Calculated design flow gpd Design flow provided 9"�Y gpd
Plan: Date V/a r((<D Number of sheets / Revision Date
Description of Soil(s) 5r_ --e-
Soil Evaluator Form No. Name of Soil Evaluator
Date of E
DESCRIPTION OF REPAIRS OR ALTERATIONS '=-Y-i4 c,_-)
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.
b;
Signed c-% Dates
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
' T
No. J THE COMMONWEALTH OF MASSACHUSETTS FEE
Yva�. BOARD OF HEALTH / rl,4",
CERTIFICATE OF COMPLIANCE
Description of Work: E]Individual Component(s) Elf� Complete System %Av �7 °` W i
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( V<Abandoned ( )
by:
at
has been installed in accordance with the °visions of 310 C R 15.00 (Title 5) and the approved design p a as -built
plans relating to application No. / dated Approved Design Flow(gpd)
Installer
Designer nspector (lam Date
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. f `'/ THE COMMLNWEAL�f HfOF MASSACHUSETTS FEE ?<
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( ) Up ode (V/)'Abandon ( ) an individual sewage
disposal system at i C'_� �z�- sv�r� _�""r- S" a�� as described
in the application for Disposal System Construction Perm)t No. /0 � dated ' �i/Co
Provided: Construction shall be completed within thr P'h afe date of this permit. 11 local conditions must be met.
Date 11 ) Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN"' PUBLISHERS - BOSTON