HomeMy WebLinkAboutApp-Permit-ComplianceNo. �"C_-I(-6Zo 3 Z
� THE COMMONWEALTH OF MASSACHUSETTS
L BOARD OF HEALTH
OF
FEE
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PLICATION FOR DISPOSAL SYr>PEM CONS UCTION PERMIT
pplication for a Permit to Construct ( ) Repair ( ) Upgrade (yj Abandon ( ) - omplete System E]Individual Components
.nra)inn . O ner's Name
Type of Building:
Dwelling — No. of Bedroc
Other — Type of Building
Other fixtures
Design Flow
Plan: Date _
Title
Description of Soil(s)
Soil Evaluator Form No.
OF
Telephone #
o. of persons
?260 gpd Calculated
7 Number of sheets
RS :OR
Name of Soil Evaluator
Address
< kl AX
5 0&_j
J
Designer's Name
`0 re`s , ,_77
Telephone #
Lot Size 0,52. feet
Garbage Grinder ( )
Showers ( ), Cafeteria
flow '450 Desi n o prov�iidomed �pd
RevisiomDate Ids J)V
Date of
The undersi d a ees to instart above described Individual Sewage Disposal System in accordance with the provisions of
TLE 5 and fu ag snot to e e system in operation until a Certificate of Compliance has been issued by the Board of Health.
Inspections
ned- ate "� 1 7 /1i
C L, ( off- '} d a C.) (C '
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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No. �"����ZQ'"THE
,�COO'M, JMONWiALTH OF MASSACHUSETTS FEE
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�2�0��`� BOARD OF HEALTH ckf 303
CERTIFICATE OF COMrMANCE,)P 7_
Description of Work: ❑ Individual Component(s) omplete System Of7 3��7
The undersigned `hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded �andoned ( )
by: ii l J�Ct� ( (t" AL", c//Di/po� 1( _C 1 cx),l
at l�� 1�' J✓� ��lv�Z�
has been installed in accordance with the D.5ovisions of 310 CMR 15.00 (Title 5) and the approved design ans/as-built
plans relating to a li' t' No.
pi6' j /► (daated Approved Design'Flow (gpd)
Installer L-D))N �" b 1
Designer: i/l cif Inspector Date o� `
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
Gi�TD( Nal- Cors t72c)e,-06�
No. V�()ti DC0 ��HE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH C44 3O3
DISPOSAL SYSTEM CONSTRUCTIO ERMIT
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( Abandon ( ) an individual sewage
disposal system at %as described
in the application for Disposal System Construction Permit No. �� ^% , dated �a- n ��
Provided: Constr ction hall G
Date , be completed within bEi f the date of this permit. All local conditions must be met.
0� d Board of Health -- 0
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W
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HOBBS& WARRENTMI
PUBLISHERS - BOSTO
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