HomeMy WebLinkAboutApp-Permit-ComplianceName of Soil Evaluator
Date of Evaluation
No. 60" C" 19-3363). $ UVTV —V8-00 FEE 455.
g ' Board of Health, le- o<,e7'GG2 MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIO1N �PERMIT
Application for a Permit to Construct( ) Repair(�pgrade() Abandon() - ❑ Complete System d'Individual Components
Location ®, �- G,G
Owner's Name ,-
Map/Parcel# �O
Address t
Lot# 4120
Telephone#
Installer's Nam
Designer's Name ,
eci�o-
Address O��
Address .. Leese r Z.
Telephone#ate_ 7>� _��� —
Telephone# -
Type of Building �iw,E f v Lot Size /4, 45C gy sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3e2 gpd Calculated design flow Design flow provided 37 3 gpd
Plan: Date r.Z/�� Number of sheets Revision Date
Title ,/
Description of Soil(s) 1 %
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed tr��� %�` Date es/a d�e�
'nspections
No. V -3 ..! FEE 55, 00
COMMONWEALTH OF MASSACHUSETTS
n
Board of Health, ,� ��,���, MA.
CERTIFICATE OF COMPLIANCE
ual Component(s)❑ Com lete S tem
Description of Work: Z-; Individ p ys �(
The undersigned hereby certify tha the Sewage Disposal System; Constructed ( ), Repaired (41)/'Upgraded ( ); Abandoned
by: / tine,/ .r�i'-ri eat r� i'c»% Srr�i wasyi' s
at
has been installed i acco dance with the roviFions of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. .. dated /-/yl Approved Design Flow 3i ? (gpd)
Installer.
Designee: nspector: Date:
The issuance of this permit shall not be construed as a guaran ee that the system will function as designed.
No. f1 Q � a I ��". 8 1 Y C (yo C .S E-V—V ( CAE5 FEE 5 ,
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon ( ) an individual sewage disposal system
at G-� Z� r /moo - l- �� as described in the application for
Disposal System Construction Permit No. 1 dated
G l ` f -
S
Provided: Construction shall be completed within % rs of the date of this pe t. All local conditions must be meta
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 1 - /r! `" Board Of health