HomeMy WebLinkAboutApp-Permit-Compliance (Expired)NoTHE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD F HEALTH 1h6Z11(k)j
Li VWn OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Co em ❑ Individual Components
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_ . nT.ncarinnr _ Owne Name
Map/Parcel #
Z Installer's Name�'_ 'Oak
�4 ��fa�
iW/ O Address
Telephone #
Type of Building: /3csi S' SNe
Dwelling — No. of Bedrooms
Other — Type of Building
Other fixtures
Design Flow (min. required)
Plan: Date
Description of Soil(s)
Soil Evaluator Form No
of sheets
Name of Soil Evaluator
Name
Address
Telephone #
Lot Size Sq. feet
Garbage Grinder ( )
�rso s Showers ( ), Cafeteria ( )
ign flow gpd Design flow provided gpd
Revision Date
Date of Evaluation
D SCRIPTIOIIJLOF REPAIRS ORMYERAT A0 6
7 r i /
The undersigned agrees o install the ab ve described Individual Sewage Disposal System in accordance with the provisions of
TITLE S and further a�es �t to playejhe syi1epn] jn operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
Inspections
Date 42�z—/ 0 5
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. 0T E MMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System AAW
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, Upgraded
at I �h��) 1AII, ke-Y A
has been installed in accordance with the provisi
plans relating ttoo�pplication No. 0�1� ¢��l� daatt
Installer �c/J�e L_ J "Al "� //'
FEE )_
lea- -1112 If/ ai
),'�A'band ne Y��
of 310 CMR_15.00 (Title 5) and the approved design plans/as-built
/Z.-Z -6 S . Approved Design Flow (gpd)
G�i cir c--e—
Designer: Inspector Date
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. lJ�J"`7` THE C MONWEALTH OF MASSACHUSETTS FEE (l
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is he b grante to Qonstruct. ( ) Repair (j�l) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at `I as described
in the application for Disposal System Construction Prmit a `" `�?'v dated / -2- ' 5
Provided: Construction shall be completed within t arrof the date of this permit. All JoFal conditions must,be met.
Date /Z -0 Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96 /
FORM 1255 ,ni
(REV
//� � 5/96) H&W HOBBS&/WARRRREN PUBLISHERS - BOSTON
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