HomeMy WebLinkAboutApp-Permit-ComplianceNo.,.g0-4fDC-1'7-0088 -_ t FEE
COMMONWEUJ.&&HIt AfSACHUSETTS
L.
Board of Health,1146 ROUTE 28 , MA.
APPLICATION FOR DISP®TUTM ®NSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair&) Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location 3a AP _
Owner's Name
_ A a95;E
Map/Parcel#
Address p'
�k I(ti�,
Lot#
Telephone#
Installer's Name �— �
Designer's Name
1 V
Address (t� CJ (
Address
Telephone# 50 g — 4--7 `7 —
Telephone#
Type of Building :�,E& c.-DEoT-t A4,__ Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS :V)%5 -WA_, O&J D ,-,90X, ANb kl!;a,.
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 lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed c Date 3 - P -y cl
Inspections
�a 4 -DC -I-/-0013 B 55.00
No. r /
COMMONWEALTH V'V' �t:1"1�LTH ®F MASSAC�tJti SETTS � � `FEE (
7 �/ _ T `1 4/J
Board of Health, l A' P,HCO tJ , H , MA, ,/1_'�.�, l% 6 ��
CERTIFICATE OF COMPLIANCE
Description of Work: ) Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: CAPGW1bG (�Q!
at 3a GAAT C r.14P
has been installed in accordance with the rovisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application
//No. / 7 =� i dated �! / Approve Design Flow " (gpd)
Installer �1t�^ DE \ 1 i�%LS 1
Designer: _�j 1fl- Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. CAPE)' (ID( FEE
SETTS �Qd>, , 0
7, ;?e COMMONWEALT14 Of �TD
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(Repair(X Upgrade( ) Abandon( ) an individual sewage disposal system
at NOTis,4z�si�C)A-p� Q �7 as described in the application for
Disposal System Construction Permit No.7/ -fie / dated
Provided: Construction shall be completed within ars of the date of this per it. l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date F /?Board / Board of Health
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