HomeMy WebLinkAboutApp-Permit-ComplianceNo. N��"�13081 THE COMMONWEALTH OF MASSACHUSETTS FEE
>� BOARD„ Oy/�F�� ''��AHE14
ALTH CPQ *54-2
1
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION IDU
Application for a Permit to Construct ( ) Repair ( V<Pgrade ( ) Abandon ( ) - ❑ Complete System ;��diid.al Components
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Telephone #
Type of Building: '*-►Z
Dwelling — No. of Bedrooms
Other — Type of Building _
Other fixtures
Design Flow
Plan: Date
Address
- q TelephjQi
,T Designer's Name
Televhone #
1 Lot Size v t G / "1
�arbage Grinder (
No. of persons Showers
gpd Calculated
Number of sheets
Description of Soil(s) 'tpl&4cf1 "05101 U L
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
The
TITLE 5
Signed
.feet
), Cafeteria ( )
flow gpd Design flow provideA�9 gpd
Revision Date
Date of Evaluation 2x-1 s3 1
d agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
agrees not to place the system in operation until a Certificate of Compliance has been issuM by the Board of Health.
Date L
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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-------------------------------------------- O�DC-1% _3081 THE'COMMONW ALTH OF MASSACHUSETTS FEE r JJ•( C)'—
No.
// uAOOM BOARD OF HEALTH ori 3"22 3`l�
CFKrIFICATE OF COMPLIANCE
Description of Work: V6ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (1-1, Upgraded ( ), Abandoned ( )
by: : OHV4 ()�ODtKi 45&011TXco NDoN S CAV�7ING— J
at 7i `ice% �or�rr� f /h Il L
has been installed in accordance with t q, provisions of 31,9. CMR 15.00 (Title 5) and the approved d�stg /as -but t
plans relating to
appp..liccaattion� No. dated Approved Design Flow (gpd)
Installer C-D�^j DDK� 79 4 fe PP19 456
Designer:
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
Tot{ -o CU IJP 01Q
No. 1 -308) THE COMMONWEALTH OF MASSACHUSETTS FEE , b0
� W-114 BOARD OF HEALTH Ck*3` -�
DISPOSAL SYSTEM CONSTJJCTION PERMIT
Permission is hereby granted to Construct ( � Repair ( Up grade ( ) Abandon ( ) an individual sewage
as described
disposal system at
in the application for Disposal System Construction Permit No. `� dated
Provided: Construction shall be completed within u� o�e date of this permit. All 1" a condition us e et.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W Homs &WARREN TM PUBLISHERS BOSTON