HomeMy WebLinkAboutApp-Permit-ComplianceNo./'0 THE COMMONWEALTH OF MASSACH SETTS FEE
BOARD OF HEALTH
OF 1 r4TL.M.bv'1 • �'D``� [�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System Individual Components
/G G Yt%srL A,4 f L•�
,jcaliow e I
Map/Parcel #
� j,lo.
Lot #
�ioS? _y c_AvA-n -tom
Name
G ����nstalle O^�LU
Address 7✓
Telephone #
Owner's Name
Address
T lephon&#
D igner's Name
�ddress
Telephone #
Type of Building: SINbL% FA*- L-'r Lot Size Zy, 505 Sq. feet
Dwelling — No. of Bedrooms 3 Garbage Grinder ( )
Other — Type of Building _ No. of persons Showers ( ), Cafeteria
Other fixtures
Design Flow (min. required) 33 o gpd Calculated design flow 550 gpd Design flow provided gpd
Plan: Date /D - -3" - O Number of sheets Z Revision Date
Description of Soil(s) 'SEU ?LA•i SoiL- Lo b
Soil Evaluator Form No. Name of Soil Evaluator L, ►- D A %,11A a Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -K6?" c-ti FA,wr_n LUA C.ht F I'4-LIO AS P L PI A -
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 a d QVft agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
FORM 1 - APPLICATION FOR DSCP
Date I I- Zl- o g
DEP APPROVED FORM 5/96
-------------------------_----•----- —-------
No. /tJ THE COMMONWEALTH OF MASSACHUSETT;�"Js& L�FEE
BOARD OF H E A LT cC t.r it P ,, ,� 77L�
CERTIFICATE OF C MPLIAN E
Description of Work: ❑ Individual Component(s) Complete System -[� Z
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedl,-<,Abandoned ( )
by: PASTon_ -Vl-,- _I 6/V
at (io o S 1\'ma I'GA F L
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. /D -//0 dated /- Af 10 Approved Design Flow ✓� � % (gpd)
Installer PA;, I (tqt_ J Lx c-Av +%
Designer:+a R a Inspector � �,� (�/(/( V'L � Date
The issuance of this certificate shall not be construed as a �aran� the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. /D THE COMMONWEALTH OF MASSACHUSETTS
Yon-N'_' BOARD OF HEALTH FEE
,P'z 774
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at L Y,t 1 v Utz %t��- l.:t- ( j� q �e, L;:.Tt� as described
in the application for Disposal System Construction Permit No. le � -dated
Provided: Construction shall be completed within t�kr�r he date of this permit. All local conditions must be met.
Date f -^�� Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96 r
/FORM 1255 (REV 5/96) H&W/ H/OBBS& WARREN TM PUBLISHERS - BOSTON
f1 4 /14 /9D/ ✓ �/, `G7 5. �� S L1 ��r "aer All /,r S/ �.! X�I,iis %