HomeMy WebLinkAboutApp-Permit-ComplianceZ-,iao - r
No. 60W-DC-17-007,4HE COMMONWEALTH OF MASSACHUSETTS FEE •��
BOARD OF HEALTH Clt47(otoe
Tout r OF a�rfY1��1�rt
1f'
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (Upgrade( ) Abandon ( ) - ❑ Complete System ndividual Components
SO w 3''i c- &c- 'Z RaL
Locatio
j� S - Z n Z �
Map/Parcel #
L #
B� B 9' QO�Jot :41'04%
Installer's Name
I
Li TScc'ruIL
cc o.� c
A dress
Sob - 417n - 0LS3
Telephone #
Type of Building: R =� S l o� a t1-�! � o►
Dwelling — No. of Bedrooms Z
Other — Type of Building No.
Other fixtures
Q i' ehoxJ, Gr----r---r\
<X0 til"'. A c e Ro1,-
Address
Telephone #
�'Lo��Grau
Mae
goumcYN-6.1
Desig�neee�s Name
4),n, J3Dx 81 Yapirr,c»-il.�P�
Address
Telephone #
Lot Size Sq. feet
Garbage Grinder ( )
of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) ZZO gpd Calculated design flow gpd Design flow provided Z-" 9 gpd
Plan: Date 71. 3D - In Number of sheets Z. Revision Date
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS _0 BOX - Z- S W 9�j LI 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.
Signed 1T�� .ent- � Date 77-31- IN
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
r /
:____ No. P C47-06ggyr�THE COMMONWEALTH OF MASSA ET7`S E
4�armoL)-lh BOARD OF HEALTH
CERTIFICATE OF COMPLIANC - -
Description of Work: Individual Component(s) ❑ Complete System /J
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (✓f, Upgraded
by: X C a ✓a� -) I O&
i� •
), Abandoned ( )
at 'go ( IN , 4 �. i�nc)� P4,
has been installed in accordance with the ovisions 31 C_MR 15.00 (Title 5) and the approved desig 1 s -built
plans relating to application No. � dated % Approved Design Flow (gpd
Installer X a Ih 1& B --AZ-r 1 �L7 oJf i
Designer: ^C)c �/ c. F� o.� c r �l e Inspecto
The issuance of this certificate shall not be construed as a,;
rWA-L � s%' .. Iii►
that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
F � PB eXC AUTATI ��
No. �✓' GiA-DC-17 _00q THE COMMONWEALTH OF MASSACHUSETTS FEE S�
7 f Yarrnojvi l, BOARD OF HEALTH Ck-*( ion
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Re air (✓f Upgrade ( ) Abandon ( ) an individual sewage
disposal system at 130 e.J k"-)-- Rock RX as described
in the application for Disposal System Construction Per it No. dated �- /
Provided: Construction shall be completed withi e year�f t e date of this pe t. l local con ' i must be met.
Date Z , 7 �/ 7 Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON