HomeMy WebLinkAboutApp-Permit-ComplianceNo.D C-1%-01
4 17-)-4-4 COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
FEE W VT4Oy
d,: 700
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair *,-.Upgrade( ) Abandon() - LS'Complete System ❑ Individual Components
Location Zo __ f'
Owner's Name
Map/Parcel# 2
Address s'Q -e
Lot#
Telephone# y-�� �. _-
p
Installer's Name/-�/ ����� Ca�� C�
Designer's Name
Address_?�p �C���� S� 4.. j�gi atlrGr 7Lg
Address
Telephone# �.^�_ ?•7S d7 Z_3—
Telephone#�-
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
No. of persons
Lot Size Z !�_ sq. ft.
Garbage grinder( )
Showers ( ) , Cafeteria ( )
Design Flow (min. required) 3 ✓� C'% gpd Calculated design flow Design flow provided gpd
Plan: Date 5Z Number of sheets 4� Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS X- !90 4 c- f Z�%,a ��.G -
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 o aeration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 9ZnK/7
Inspections
FE
C®MMONWEALT14 Of MASSACHUSETTSo`er
'All
Board of Health, y'cor �Gr-G G� MA. \0`
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 016omplete System
The undersigned hereby certify thaVthe Sewage Disposal System; Constructed ( ), Repaired (,e Upgraded ( ), Abandoned ( )
by: f o f -Z., a,,,�,, "-) f
at ZC2
has been installed in acc daze with the rovis ns of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. - ,dated �: 17.. Approved Design Flow (gpd)
Installer — �' _ ! 1r) ; /G . 1--A ,a
Designer: 412,6'a *:n!f Inspector: Date: / �r
The issuance of this permit shall not be construed as a guaranithat the system will function as designed.
No. i? F� 1 / ' 63 .3 ! � (U C SV C- FEE
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (4,1" Upgrade( ) Abandon ( ) an individual sewage disposal system
at a, as described in the application for
Disposal System Construction Permit No. dated
c7�
Provided: Construction shall be completed within s o the date of this pernSit. jAll local condi ' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 2oard of Health !
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