HomeMy WebLinkAboutApp-Permit-ComplianceNo. THE COMMONWEALTH OF MASSACHUSETTS FEES" C/
/� BOARD OF HEALTH_If_
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair (. ) Upgrade ( ) Abandon ( ) - ❑ Complete System []Individual Components
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Map/Parcel #
Lot #
Mr Ps+Au
Addre
Telephone #
9 9 Owner's Name
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ele�p—h}one #
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U , y L46 _lI address
CTellephone #
Type of Building: `�, _-. L-rl e _� Lot'Size 43 - Sit
Dwelling — No. of Bedrooms Garbage Grinder ( )
Other — Type of Building No: of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (min. required) gpd Calculated design flow #� gpd Design flow provided 11�` /gpd
Plan: Date n I t D Number of sheets Revision Date
Title `Tl+ -Lc S 1 kC—
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the s stem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Lae1� Date 1 /t `1 1 l j
n1
Inspections ! 7 / J- Is► d tT�,/ -b t b - w `-/ -1 IcJ } w d Tc�_ C -
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. f/ Q_ THE COMMONWEALTH OF? MASSACHUSETTS FEE `5 4a
14_1 BOARD OF HEALTH ,61
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Compgnent(s) E] Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded �), Abandoned
at
has been installed in accordance with th provisions of 310 CMR 15.00 (Title 5) and the approved desig ans/as-built
plans relating to application No. �% dated ✓ �F ` �r Approved Design Flow (gpd)
Installer7
Designer.
esi ner. (' f: a Inspector hu Date Z i
The issuance of this certificate shall not be construed as a guarantee"that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. THE COMMONWEALTH OF MASSACHUSETTS FEES G�
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct_ ( ) Repair ( ) Upgrade�(p Abandon ( ) an individual sewage
disposal system at "'I `"1 (V � i t 1 �Di i.1. f,C. Li `. J6, r`1 z'�ut'�� r� �'� as described
/
in the application for Disposal System Construction Permit No. / �r dated /- 4?
Provided: Construction shall be completed within Il=@-yea�f the date of this permit. ll,local conditions must be met.
Date / - /IF // Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
�; FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON