HomeMy WebLinkAboutApp-Permit-ComplianceNo. BOOC---x2 16,0� � � FEE
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Board of Health, �rr�ce/1 , MA. � 2
APPLICATION FOP DISPOSAL SYSTEM C®NSTR ION PERNHT
Application for a Permit to Construct( ) Repair l4pgrade ( ) Abandon( ) - ❑ Complete System L7lndividual Components
Location -27_,,e
Owner's Name
Map/Parcel# _
Address
Lot#
Telephone# 5-o,47- 77- -_ d, -S cf
Installer's Name , C -e be rar,,,o
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Designer's Name
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Address 3cj-® Cie`o� S ., raav
Address/.Z
Telephone#
Telephone# .*-O _ 7r _
Type of Building Lot Size 7 3., 0 2 Z sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons A 5- Showers( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) ? gpd Calculated design flow Design flow provided 34a'. 7 gpd
Plan: Date 7 / S///1 Number of sheets :Z Revision Date
Title
Description of Soil(s) -
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONSsy- s�� Sit �'v��P sd� f3 O� /W
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Cfio...��� � tr�«� Sto •rE j � X 7 s- �r z �
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 o place the system in operation until a Certificate "Compliance, has been issued by the Board of Health.
Signed / ��2'-�- Date
Inspections
No. [CW)c FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, X, v Uri A MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) �omplete System 2 / j � 404eo�
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (-),/Upgraded ( ), Abandoned ( )
by: S
at
has been installed incco d e with the rovisro s of,340 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated - Approved Design Flow gpd)
Installer .�''�% r-. - ';' __.. sCfl�%/ It- �'i7+frd �q'/
Designer: 1S / lfuL AwA `C-3 - Inspector: i d%s�' ',✓✓°Date: '7- i1 -1
The issuance of this permit shall not be construed as a gu tee that the system will function as designed.
No. 4DC-1 Ca �, . f �" C00 J AJC VCS FEE Xs'Tt G�
I �COMMONWEALTH Of MASSAC14USETTS
Board of HealthyMA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( v)/Upgrade ( ) Abandon ( ) an individual sewage disposal system
at {� as described in the application for
Disposal System Construction Permit No. /4. dated �Q
Provided: Construction shall be completed within dix"Mthe date of this All local cop4itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date //` 4Q Board of Health �-