HomeMy WebLinkAboutApp-Permit-ComplianceNo. 8Qk C—t8 ZZQZTHE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH &s40$��
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System Mdual Components
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Lot #'
114 -7— Insall
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Telephone #
Type of Building:
Dwelling — No. of Bedroc
Other — Type of Building
Other fixtures
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Telephone #
y ��/1(�_� Lot Size Sq. feet
113 Garbage Grinder ( )
No. of persons Showers ( ), Cafeteria
Design Flow (m'n. re uirM) �� gpd Calculated design flow gpd Design ow p oviApd gpd
Plan: Date Number of sheets Revision Date ���
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Hao zo d 6 ox 64 N 10 Gh e,- m ,�e/�S
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu agrees not to place the syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date I
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
...,No. [�6Npc-18-z2c2- TH COMMONWEALTH OF MASSACHUSETTS FEE
Cj (MQ h BOARD OF HEALTH a*SSZ-
C kRTIFICATE OF COMPLIANCE
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Description of Work: >tvidual Component(s) E] Complete System
The undersigned ereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: {
at 140 AAo("1+nQ))-e l'u-e -\AJ' Q(moLA
has been installed in accordance 'th th provisions df 31 C R 5.00 (Title 5) and the approved design-plans/as-built
plans reM'o a plication No. _ Y dated L a Approved Design Flow (gpd)
'((��� � `t b
Designer t_) L'. 1jU for Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICAT OF COMPLIANCE DEP APPROVED FORM 5/96
Com. V '�
No..ZZ/G+�^E COMMONWEALTH OF MASSACHUSETTS FEE - 0
(MQ BOARD OF HEALTH�?���
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby grante tq Construct ( ) Repair ( ) Upgrade ) Abandon(( ) an individual sewage
disposal system at y --' c?n � G �v d d711� as described
in the application for Disposal System Construction Permit No. G ! dated o1 -
Provided: Constr tion shal).be completed within three years of the date of this permi loc l conditions must be met.
Date Board of Health
FORM 2 - DSC;P DEP APPROVED FORM 5/96
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FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS - BOSTON