HomeMy WebLinkAboutApp-Permit-Compliance: o0
No. THE COMMONWEALTH OF MASSACHUSETTS FEE � � •
BOARD OF HEALTH?3I�
OF 92►.i- M,0o-AV\
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair (v/ Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components
Z2. Menil55c3_. DriuC_
Lo ion
Map/Parcel #
Lot #
A � R F-%(ZOyv ;O,n
Installer's Name I
TCa-. CrrL, L-*-) rrcAdat.)t
Ad ress
SO& q,7,7- 0463
Telephone #
fo V C 1•-
Owner's Name
;i
ZZ fl'1c19 55v- JIVc.
Address
Telephone #
Designer's Name
Address
Telephone #
Type of Building: Lot Size Sq. feet
Dwelling — No. of Bedrooms 13 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 gpd
Plan: Date Number of sheets Revision Date
Title
Descriptiota 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 system in operation until a Certificate of Compliance has been issued by the Board of Health.
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
_
No. Vy D(- 19 -31 OTHE COMMONWEALTH OF MAACH . SETT 41FEE
rnoo� VN BOARD OF HEALTnF /
CERTIFICATE OF COMPLIANCE / ��
Description of Work: [Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (4,Ppgfted ( ), Abandoned ( )
by: EXCa Vc.' t O n
at 7ZZ
has been installed in accordance w'th the rovisions 310 CMR 1 (Title 5) and the approved design lapss-built
plans relating to application No. l d' /� dated `l Approved Design Flow 3 ''. 0(gpd)
Installer J -i *- 16 EXCo.
Designer: --- Inspector
6-Z-12-
The issuance of this certificate shall not be construed as a Oarantee-that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. 300 �c-�e-3 7�HE COMMONWEALTH OF MASSACHUSETTS FEE � 5J 00
! �—/,>V Y,--,irnporlV, BOARD OF HEALTH ck-t�-731-7
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair (✓S Upgrade ( ) Abandon ( ) an individual sewage
disposal system at 7-7- Mc -);,55,a. D (R ( as desuibed
in the application for Disposal System Construction Permit No. �� datedri-
Provided: Construction shall be completed within three years of the date of this permit focal cond it' t be met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5//96) H&W OBBS& WARREN TM PUBLISHERyr- BQSTON/