HomeMy WebLinkAboutApp-Permit-Compliance6L -OTR - 17 00511'
No. 60WDGI.'-- S'f 7 THE COMMONWEALTH OF MASSACHUSETTS FEE Ob
BOARD OF HEALTH 55191
'a Wn OF 6M /_ T f '
AP�TION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
A\1" Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - E]Complete System E]Individual Components
A4
Map/Parcel #
Lot #
X�.d1/CZ���
/ Qr r,�[SI IL .�I�saC�G.��b
6 Dg -, 7 % 6 t��J--�'ss
Telephone #
Telephone #
Type of Building: GQ- Lot Size Sq. feet
Dwelling — No. of Bedrooms Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures rr ``,, jj
Design Flow (min.. required) �Q gpd Calculated des* n flow 9� gpd Design flow provide gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator ��rh� f Date of Evaluation ' a4
DESCRIPTION OF REPAIRS OR ALTERATIONS tl ZO 46DY.b) iJ la 5ab ( bel S
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and furthergglres not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections Z _ _ ( C -C SG L
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
o—_—_.__---- -- — — — ———— — — — — —— <----_____--
No. G0F Dr -47-39q( /TH COMMONWEALTH OF MASSACHUSETTS FEE
/
7 -?7 I BOARD OF HEALTH
/ C TIFICA_TE �01F COMPLIANCE
Description of Work: dividual Component(sl) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (&4-,1X'bandoned ( )
at 200 'Wi late) SI (
has been installed in accordance with
plans relayapplication /N''o. [�
Installer T'0VDfT_T_ l� 4 LrC
Designer: 1 10.11
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF'CMPLIANCE DEP APPROVED FORM 5/96
310MR 15.00 (Title 5) and the approved design / -built
��/% r/ -. Approved Design Flow (gpd)
No. V, 601)-i-7-3(fi7HE OMMONWEALTH OF MASSACHUSETTS FEE `�'Sj. U�
/ %97 BOARD OF HEALTH &_*1589
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is
disposal system at
( ) Repair
\1n ( cy) ")/
in the application for Disposal System Construction Permit No. / /
( ) Abandon ( ) an individual sewage
as described
dated �' , /:7
Provided: Construction shall be completed within three years of the date of this mi �lll local condi'
must be met.
Date ��� Board of Heal
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORMr 1255 (REV 5/96) `/ H&W HOBBS&WARREN TM PUB ISHERS - BOSTON