HomeMy WebLinkAboutApp-Permit-Compliance' No. C� �` FEE JV' OU
Board of Health, 4C, ROUTE 28 , MA
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APPLICATION FOR DISPOSAO TORST CTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade�/Abandon( ) - ❑ Complete System /Individual Components
Location /,j
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Owner's Name S pNr j'l�y.►✓
Map/Parcel# In qy0 016-
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Address && ge/ A 64e -A." v Z'
Lot#
Telephone# 5V0"-,3'3 cUOJ
Installer's Name
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Designer's Name 6 --Pc- e�/-ac
Address olfe
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Address -IV, In Cf 5�7- w, ckw
Telephone#
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Telephone# S`6p- � dli
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Type of Building W1rAl �j Lot Size / • � /� - sq. ft.
Dwelling - No. of Bedrooms ov Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) -3-3 V gpd Calculated design flow Design flow provided -&,gpd
Plan: Date � - 3 d � Number of sheets _ _ Revision Date /
Title
Description of Soil (s) M -e (,C1-, t C,�,ce`J-f
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS N G% QUU
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signe L�:I'rtitR�'`✓ %!'� Oy/1✓�,�t. Date �T�6
Inspections " ! 4 L
No. 1900-17-,-3 FEET) du
COMMO1��LT14 Of MASSACHUSETTS °'k �
Board of Health, ,, �-qA1`1 o (, T F/ , MA.
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CERTIFICATE Of COMPLIANCE
Description of Work: ?1{ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( bandoned
at
has been installed in ccordance with the provisionsof 3 yCMR f5.00 (Title 5) ,and the approved desigp,plans/as-built plans relating to
application No. - dated --27 ��
Ohl Design Flow (gpd)
Installer
Designer: 6 � C1i? d4Z2 .Inspector: _ f /fir. ' ` Date:
The issuance, of this permit shall not be construed as a guarantee that the system will function as designed
No., LO �/� FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, , / r9 0 t. , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade �bandon ( ) an individual sewage disposal system
at %-�' �S'� !� d��/ /F/t' as described in the application for
Disposal System Construction Permit No. � dated
Provided: Construction shall be completed within k' res of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 6 ^ Board of Health