HomeMy WebLinkAboutApp-Permit-ComplianceNo. Bonn- FEE �V +: 0
18 !Jo>39y
Board of Health, —/'ter/ +teedp MA.
!,r// PLI CAT ION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
i
Aplication for a Permit to Construct( ) Repair(L1(pgrade() Abandon() - Ertomplete System ❑ Individual Components
Location l ;Z �F� - 1
Owner's Name
Map/Parcel# Sa
Address
Lot# r
Telephone#
Installer's Name , Ce`�a c P <<
Designer's Name
Address 3 y�U _ ov�c
Address
Telephone# a� _ �.�-,
Telephone#r�yr-
Type of Building�� �� a�.��i Lot Size e/9F sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. l'equired) 33 CJ gpd Calculated design flow Design flow provided 3 �%Q gpd
Plan: Date i//�' %/�� Number of sheets ✓ Revision Date
Titled
Description of Sbil(s)l.rP
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS�`/��
.
Ar- r 2-S-
he undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to notio place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 9�-�� ���� -�~ Date
Inspections 101-/l r7 -be Cepa
No. U H C, / " V 30 7 FEE `Y 5�5, 0o
COMMONWEALTH OF/MASSACHUSETTS
Board of Health, vx c4- MA. 0 ��
CERTIFICATE Of COMPLIANCE t U
Description of Work: ❑ Individual Component(s) 2peomplete System
The undersigned hereby certify that the S Wage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
by: 5;:
at
has been installed in accorda}�ce with the rovi iotas of 3�0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 7 ` b dated Approved Design Flow (gpd)
Installer
Designer: -D0 jj t°,1 C-P%Ptw &WWI N , Inspector: !F .# Date: fd
The issuance of this permit shall not be construed as a guarantee that d, system will function as designed.
No. VGt,V 307 CAP& CCD Se IPC JvC--�'�"'17- COMMONWEALT14 OF MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
5
Permission is hereby granted to; Construct( ) Reepair4.-�Upgrade ( ) Abandon ( ) an individual sewage disposal system
at /..:;, zol'- as described in the application for
Disposal System Construction Permit No. t7--,-) S Y, dated
Provided: Construction shall be completed within tInye'ears of�the�datSe� of this permit. All local conditions must be met.
Form 1255 Rev5/96 A Sulkin Co. Boston, M Date' 'Board of Health