HomeMy WebLinkAboutApp-Permit-ComplianceNo. 160" C— 0-q6 (%off zw
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-770 COMMONWEALT14 OF MASSAC14USETTS -K
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Board of Health,MA. 17
APPI.ICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
p 3lication for a Permit to Construct( ) Repair(1/"UpgradeO Abandon( ❑ Complete System
f
LJ Components
ocation 57
Owner's Name �- Q
Map/Parcel# ,�'
Addressf
Lot#
Telephone# -ZO 3 - 7 P
Installer's Name h �G�� d
Designer's Name�'a,��
AddressAddress
Telephone# Gam- �.7�- - Z�z r
Telephone#f-
Type of Building IL/ Lot Size Z4 o 0 o sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. re uired) ,F 57 O gpd Calculated design flow
Plan: Date 759% Number of sheets
T1/_ S- -r-e- �o
5@14M
Description of Soil (s) _
Soil Evaluator Form No.
I's,
Name of Soil Evaluator
Design flow provided 27 4l9 gpd
Revision Date
Date of Evaluation
OF REPAIRS OR ALTERATIONS 7—
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees
stto%not to place the system in o�erati_o_n until a Certificate of Compliance has been issued by the Board of Health.
Signed J_c �®'� — ' Date e51
Inspections
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No. kC 11 7- -7 COMMONWEALTH OF AC14U Ell C � w
l Board of Health, .rte r.� y''� MA. " J
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Q -Complete System
The undersigned hereby certify thatth Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned
( )
by:
ltrC
at ✓ v,G,��
has been installe in ac�g jance with the rovisio is of ],0 CMR 15.00, (Title 5) an�W, roved design plans/as-built plans relating to
application No.r f ! dated /. Approved Design Flow s� ( d)
Installer ' ' N Aff
Designer: __1) 0 3,-,) CftPjE Inspector: ( Date:
The issuance of this permit shall not be construed as a guargx a that the system will function as dsigned.
No. ,'c,)l� r" 1 / "' '1 l.' G.�Y�-z cAi2e (4_�
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COMMONWFAIT14: OF MASSACHUSETTS
Board of Health, MA•
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (t -'j Upgrade( ) Abandon ( ) an individual sewage disposal system
at _ ._.•'�•���� / as described in the application for
Disposal System Construction Permit No. �/�> dated n
,.-)
Provided: Construction shall be completed within thx*&-Ars o t?ee date of this per i�local corUjitiqns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 7— / '�__PBoard of Health C..•1"