HomeMy WebLinkAboutApp-Permit-ComplianceNo. 064VC48--3382 �t.(g 60-723a
19-- 8 *C)C MMONWEALTH OF MASSACHUSETTS
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Board of Health, �vr<✓��1 MA.PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMI1
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FEE 6 5 V0
Application for a Permit to Construct( ) Repair( ). Upgrade(,rrbandon() - ❑ Complete System`1S15dividual Components
Location
Owner's Name �7 W�
a
Map/Parcel# j 4/ l'
Address6-/ g--
Lot#
Telephone# e-j 7_ T.�6
Installer's Name Q� S .
Designer's Name
6
Address
Address
Telephone# �y
Telephone#
Type of Building
Dwelling - No. of
Other - Type of Building
No. of persons
sq. ft.
Garbage grinder (�
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ® gpd Calculated design flow Design flow provided �9p5T gpd
Plan: Date �jj/,?5��� Number of sheets / Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ��/�
2cj`0o /G�t� ,7 �oos.�o.►�i�'-�.�� �r� ml� /'S'Om�fsoc�o G vsf�!% �—��w ,f% ,G�O'�y/
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no lace the system in operatioduntil a Certificate of Compliance has been issued by the Board of Health.
Signed-a!i ,ram'��•'� --® Date
Inspections
S
r
No. ( 33'32— IP FEE
y�25COMMONWEALTH-OF MASSACHUSETTS'
Board of Health;
E 1IFICATE OP COMPLIANCE
Description of Work: ❑ Individtualtomponent(s)'' Complete System
The'undersigned hereby certify th the Sewage Disposal System; �,6Qnstructed ( ), Repaired (graded ( ), Abandoned ( )
by:
at -
has beendristalled ip ccordLW with the provisions gf>310 CMR 15.00 (Title 5) and the approved design :plans/as-built plans relating to
application No:_�... datedApproved°Design Flow (gpd)
Installer
�/� �i�
Designer: )Cl,�til/t c .� %c/G't'e!r� `t5'l Inspector:'; Date:
The issuance of this permit shall not be construed as a guarantedtthaVdie system will function as &,signed.
No. - � o' � � 9 zV I cET FEE co
COMMONWEALTH Of MASSAC14USETTS
Board of Health,, f-fii MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( =} Repair (4<-Up grade ( ) Abandon ( ) an individual sewage disposal system
at !� mac® ~ a-�7p` �-%�I as described in the application for
Disposal System Construction Permit No. 1 dated /I
Provided: Construction shall be completed within tb=.Jear� t;le date of this per 't 1 local conditions must be met.
Form 1255 Rev.5/96 A.M. Sulkin Co. Boston, MA Date / t+ Board of
Health—<