HomeMy WebLinkAboutApp-Permit-ComplianceNO. � — (7-0P?TH COMMONWEALTH OF MASSACHUSETTS FEE 00
/�_�7� BOARD OF HEALTH 647%
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APPLICATION FOR DISPOSAL SYSTEM CONS)PRUCTION PERMIT
Application for a Permit to Construct( ) Repair ( ) Upgrade �andon ( ) - omplete System ❑ Individual Components
3S� leason Ave
3 7 42
Map/Paarrcce�l(#
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PET Inst II sName /
509— 44-77—v d s
Telephone #
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Type of Building: �
Dwelling — No. of Bedrooms
Other — Type of Building
Other fixtures
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nv veph✓_f o s on
5a� 93 3 •zl -rdys
Telephone #
Lot Size Sq. feet
Garbage Grinder ( )
of persons Showers ( ), Cafeteria
Design Flow (min. required) 22D gpd Calculated design flow gpd Design flow provided 3� gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
1 TOO OW 1.1 10 ST H 2 o 146 o.K 4-rP Arj¢ S-.5 u rev v nL,P� ,Qv s
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu—Z3rees not to place the system ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date I Q I r]
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. 2'C'41—by Z� HE. COMMONWEALTH OF MASSACHUSETTS FEE ` n"_,�1`�®
/7 �,� I . _.: ( { --�-BOARD OF HEALTH ; t (a� 7 7
C RTIFICATE OF COWLIANCE
Description of Work: ❑ Individual Component(s) Pocomplete System
The undersigned h by certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: �) 1 � C-. \)(( (-\ \j u ) I / . 4 1
at 0N
has been installed in accordance with the visions )of 310 CM 15.00 (Title 5) and the approved desi n plans/as-built
plans relaying to application No. 7 dated/t) :1 7"-/ : Approved Design Flow �(gPd)
Installer % but. �-'
Designer: D C t \N I r (Jill tc kJr Inspector�n'
1 l Date
The issuance of this certificate shall not be construed as uathat the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No.l�i THE COMMONWEALTH OF MASSACHUSETTS FEE 5j, co
—,� 74 C} J 1 ))LL,,, 1 `"OARD OF HEALTH 4 y%-7
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hererantef to Construct ( )Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at ,by� l f' C I S C� f 1 A\:t > }, as described
in the application for Disposal System Construction Permit No./ 7- Z - "T/ dated,/6r -7-
Provided: Construction shall be completed within three years of the date of this permit. 1 al conditio t be met.
Date /D �� r Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON