HomeMy WebLinkAboutApp-Permit-ComplianceNo. o I.i C FEEiV V
�9 COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA. ' /Qv 00
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairt4pgrade( ) Abandon( ) - WIMplete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# 3� %o��
Address �67 sw T e--Y76
Lot#
Telephone# 7ZV _ 7 R _
Installer's Name `?
Designer's Name
Oc,1v✓ 2L-®e i4' iC-ve ev
Address 3J`�-o vi' YT ,`yam
Address cf3 oi<H sT dLed<r �o
Telephone# ---Pep 7s _ ��yzs-
Telephone#
Type of Building A ��s., . %G Lot Size sq. ft.
Dwelling - No. of Bedrooms �j Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ✓? 30 gpd Calculated design flow Design flow provided 3 3 3 gpd
Plan: Date z z/�, I- Number of sheets / Revision Date
Title -777t/; 5y', f,— rG'/cam
Descri tion of Soil s
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
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 to place the system in operatioduntil a Certificate of Com fiance has been issued by the Board of Health.
Si ned ems--✓ i'"�-'�- Date 2.7
Inspections
J
No. " d - V f FEE i' 0 Q
COMMONWEALTH OF MASSACHUSETTS
CA4 2-510
Board of Health, /GG-s aiF MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ZI-Complete System
The undersigned hereby certify th the Sewage Disposal System; Constructed ( ), Repaired (! , Clpgraded (-), Abandoned O
by: "�-
at
has been installe accordance accordanwith the ovisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. f— _ dated �/ 3. Approved Design Flow -s (gpd)
Installer- - 7
Designer: DoWt, CA PO� Inspector: Date: /!
The issuance of this permit shall not be construed as a guarani a that the system will function as designed.
No. boqlpcioo-015-s- Coec C n o S em C eoI FEE . 00
C®MMONWELT1 Of MASSAC14USETTS
Board of Health, r <G Gl MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair�--KUpgrade( ) Abandon( ) an individual sewage disposal system
at i�a rd as described in the application for
Disposal System Construction Permit No.� dated`
Provided: Construction shall be completed within �f ar"s of 2e date of this 't. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston MA Date-� 7 �l " Board of Health l �